TY 2010 Form 990

(A) Name and business address	(B) Description of services	(C) Compensation
MT ASCUTNEY HOSP AND HEALTH CTR 289 COUNTY RD WINDSOR,VT05089	PROFESSIONAL SERVICE	554,930
LAVALLEE BRENSINGER ARCHITECTS 155 DOW ST SUITE 400 MANCHESTER,NH03101	ARCHITECTS	523,136
UPPER VALLEY NEUROLOGY 106 HANOVER ST LEBANON,NH03766	PROFESSIONAL SERVICE	266,765
VALLEY REGIONAL HOSPITAL 243 ELM ST CLAREMONT,NH03743	LAB SERVICES	191,690
COMBINED SERVICES PO BOX 1320 CONCORD,NH03301	PLAN ADMINISTRATION	141,693
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization 7

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the U.S. See Part IV, line 21	41,450	41,450
2	Grants and other assistance to individuals in the U.S. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the U.S. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	610,657	73,289	537,368
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	22,431,256	21,641,484	611,629	178,143
8	Pension plan contributions (include section 401(k) and section 403(b) employer contributions) ....	679,040	640,175	33,601	5,264
9	Other employee benefits .......	3,459,014	3,298,555	133,609	26,850
10	Payroll taxes ...........	1,553,757	1,442,041	99,907	11,809
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	48,872	6,833	42,039
c	Accounting ...........	50,150		50,150
d	Lobbying ...........	0
e	Professional fundraising. See Part IV, line 17..	86,744			86,744
f	Investment management fees ......	0
g	Other ..........	5,837,459	5,392,445	417,938	27,076
12	Advertising and promotion ....	2,178	360	1,814	4
13	Office expenses .......	1,350,990	1,054,689	277,561	18,740
14	Information technology ......	80,285	76,608	2,914	763
15	Royalties ..	0
16	Occupancy ...........	978,255	795,821	174,687	7,747
17	Travel ............	201,365	179,980	19,655	1,730
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	0
20	Interest ...........	325,233	252,446	70,023	2,764
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	1,401,317	1,097,091	304,226
23	Insurance ..............	452,859	442,956	9,527	376
24	Other expenses. Itemize expenses not covered above. (Expenses grouped together and labeled miscellaneous may not exceed 5% of total expenses shown on line 25 below.)
a	BAD DEBT EXPENSE	2,596,394	2,596,394
b	MEDICAID ENHANCEMENT TAX	1,780,816	1,780,816
c	EQUIPMENT RENTAL/MAINTENANCE	498,631	484,592	13,995	44
d	MEDICAL SUPPLIES/EQUIPMENT	4,298,449	4,296,546	1,678	225
e	ADMIN EXPENSE PAID TO AHS	483,311		483,311
f	All other expenses	70,146	58,261	10,111	1,774
25	Total functional expenses. Add lines 1 through 24f	49,318,628	45,652,832	3,295,743	370,053
26	Joint costs. Check here if following SOP 98-2 (ASC 958-720). Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation

Part X Balance Sheet
	1	Cashnon-interest-bearing ..........	1,955	1	296,478
2	Savings and temporary cash investments .......	4,464,824	2	6,445,524
3	Pledges and grants receivable, net .........	8,764	3	73,430
4	Accounts receivable, net .........	6,151,124	4	7,551,295
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........		5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........		6
7	Notes and loans receivable, net .............		7
8	Inventories for sale or use ..............	1,158,009	8	1,220,966
9	Prepaid expenses and deferred charges ............	194,503	9	372,898
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	34,488,976
b	Less: accumulated depreciation. .....	10b	22,113,583	11,400,298	10c	12,375,393
11	Investments—publicly traded securities ..........	2,555,238	11	2,827,079
12	Investments—other securities. See Part IV, line 11 ......	8,500	12	8,500
13	Investments—program-related. See Part IV, line 11 ..		13
14	Intangible assets .........	150,291	14	128,010
15	Other assets. See Part IV, line 11 ...........	2,298,999	15	2,348,299
16	Total assets. Add lines 1 through 15 (must equal line 34)...	28,392,505	16	33,647,872
	17	Accounts payable and accrued expenses .	6,020,355	17	6,379,747
18	Grants payable ..........		18
19	Deferred revenue ..........		19
20	Tax-exempt bond liabilities ..........	9,021,000	20	12,144,107
21	Escrow or custodial account liability. Complete Part IV of Schedule D..		21
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........		22
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ....		24	495,000
25	Other liabilities. Complete Part X of Schedule D.....	236,800	25	606,026
26	Total liabilities. Add lines 17 through 25.....	15,278,155	26	19,624,880
		Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....	11,576,659	27	13,051,788
28	Temporarily restricted net assets .....	1,509,626	28	945,364
29	Permanently restricted net assets .....	28,065	29	25,840
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances .....	13,114,350	33	14,022,992
34	Total liabilities and net assets/fund balances .....	28,392,505	34	33,647,872

- TIN:

SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section
4947(a)(1) nonexempt charitable trust.

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization

Alice Peck Day Memorial Hospital

Employer identification number

02-0222791

Part I

Reason for Public Charity Status (All organizations must complete this part.) See instructions

The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)

A church, convention of churches, or association of churches. section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in

section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of

its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses

acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)

An organization organized and operated exclusively to test for public safety. Seesection 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Other

By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).

If the organization received a written determination from the IRS that it is a Type I, Type II or Type III supporting organization, check this box ..................................................

Since August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?

(i) a person who directly or indirectly controls, either alone or together with persons described in (ii)

Yes

and (iii) below, the governing body of the the supported organization? ................

11g(i)

(ii) a family member of a person described in (i) above? ......................

11g(ii)

(iii) a 35% controlled entity of a person described in (i) or (ii) above? ................

11g(iii)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(iv) Is the organization in col. (i) listed in your governing document?		(v) Did you notify the organization in col. (i) of your support?		(vi) Is the organization in col. (i) organized in the U.S.?		(vii) Amount of support?
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of support?


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2010

Page 2

Part II

Support Schedule for Organizations Described in IRC 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

Calendar year(or fiscal year beginning in)		(a) 2006	(b) 2007	(c) 2008	(d) 2009	(e) 2010	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") ....
2	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3..
5	The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f)..
6	Public Support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year(or fiscal year beginning in)		(a) 2006	(b) 2007	(c) 2008	(d) 2009	(e) 2010	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
9	Net income from unrelated business activities, whether or not the business is regularly carried on..
10	Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets..
11	Total support (Add lines 7 through 10).

Gross receipts from related activities, etc. (See instructions.) ..................

First Five Years If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here.......................................... right arrow

Section C. Computation of Public Support Percentage

Public Support Percentage for 2010 (line 6 column (f) divided by line 11 column (f)) .........

Public Support Percentage for 2009 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2010. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ...................... right arrow

33 1/3% support test—2009. If the organization did not check the box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2010. If the organization did not check a box on line 13, 16a, or 16b and line 14
is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly supported
organization .................................................. right arrow

10%-facts-and-circumstances test—2009. If the organization did not check a box on line 13, 16a, 16b, or 17a and line
15 is 10% or more, and if the organization meets the "facts and circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts and circumstances" test. The organization qualifies as a publicly
supported organization .............................................. right arrow

Private Foundation If the organization did not check a box on line 13, 16a, 16b, 17a or 17b, check this box and see
instructions ................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2010

Page 3

Part III

Support Schedule for Organizations Described in IRC 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

Calendar year(or fiscal year beginning in)		(a) 2006	(b) 2007	(c) 2008	(d) 2009	(e) 2010	(f) Total
1	Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .
2	Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose......
3	Gross receipts from activities that are not an unrelated trade or business under section 513..
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...
5	The value of services or facilities furnished by a governmental unit to the organization without charge..
6	Total. Add lines 1 through 5.
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons...
b	Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year.
c	Add lines 7a and 7b..
8	Public Support (Subtract line 7c from line 6.)

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2006	(b) 2007	(c) 2008	(d) 2009	(e) 2010	(f) Total
9	Amounts from line 6...
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.
c	Add lines 10a and 10b.
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.)
13	Total support (Add lines 9, 10c, 11 and 12.).

Section C. Computation of Public Support Percentage

Public Support Percentage for 2010 (line 8 column (f) divided by line 13 column (f)) .........

Public support percentage from 2009 Schedule A, Part III, line 15 ...............

Section D. Computation of Investment Income Percentage

Investment income percentage for 2010 (line 10c column (f) divided by line 13 column (f)) ......

Investment income percentage from 2009 Schedule A, Part III, line 17 .............

19a

33 1/3% support tests—2010. If the organization did not check the box on line 14, and line 15 is more than 33 1/3% and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .......... right arrow

33 1/3% support tests—2009. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization .... right arrow

Private Foundation If the organization did not check a box on line 14, 19a or 19b, check this box and see instructions ..... right arrow

Schedule A (Form 990 or 990-EZ) 2010

Page 4

Part IV

Supplemental Information. Supplemental Information. Complete this part to provide the explanation required by Part II, line 10; Part II, line 17a or 17b; or Part III, line 12. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

OMB No. 1545-0047

2010

Name of organization

Alice Peck Day Memorial Hospital

Employer identification number

02-0222791

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule.
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.

Special Rules

For a section 501(c)(3) organization filing Form 990 or 990-EZ, that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi), and received from any one contributor, during the year, a contribution of the
greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For a section 501(c)(7), (8), or (10) organization filing Form 990, or 990-EZ, that received from any one contributor,
during the year, aggregate contributions of more than $1,000 for use exclusively for religious, charitable,
scientific, literary, or educational purposes, or the prevention of cruelty to children or animals. Complete Parts I, II, and
III.

For a section 501(c)(7), (8), or (10) organization filing Form 990, or 990-EZ, that received from any one contributor,
during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not aggregate to more than $1,000. If this box is checked, enter here the total contributions that were received during
the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or more
during the year. ......................... Arrow Bullet

Caution. An Organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2 of its Form 990, or check the box in the heading of its
Form 990-EZ, or on line 2 of its Form 990-PF, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2010)

Name of organization Alice Peck Day Memorial Hospital
Schedule B (Form 990, 990-EZ, or 990-PF) (2010) Page 1 of 1 of Part I
Part I	Contributors (see Instructions)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
RESTRICTED	RESTRICTED RESTRICTED RESTRICTED RESTRICTED, RESTRICTED RESTRICTED	$RESTRICTED	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Aggregate contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II if there is a noncash contribution.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Name of organization Alice Peck Day Memorial Hospital
Schedule B (Form 990, 990-EZ, or 990-PF) (2010) Page 1 of 1 of Part II
Part II	Noncash Property (see Instructions)
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Page 1 of 1 of Part III

Name of organization
Alice Peck Day Memorial Hospital

Employer identification number

02-0222791

Part III

Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
aggregating more than $1,000 for the year. (Complete columns (a) through (e) and the following line entry.)
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b)
Purpose of gift

(d)
Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

Schedule B (Form 990, 990-EZ, or 990-PF) (2010)

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet

Complete if the organization is described below.
SchCMd Bullet

Attach to Form 990 or Form 990-EZ. SchCMd Bullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

If the organization answered “Yes,” to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered “Yes,” to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)) Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered “Yes,” to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35a (Proxy Tax), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

Alice Peck Day Memorial Hospital

Employer identification number

02-0222791

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization's direct and indirect political campaign activities on behalf of or in opposition to candidates for public office in Part IV.

Political expenditures .................................... SchCMd Bullet

Volunteer hours ........................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ......... SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ...... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............

Yes No

Was a correction made? .........................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c) except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt funtion activities .................................... SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b.. SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ..........................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.

For Privacy Act and Paperwork Reduction Act Notice, see the instructions for Form 990.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2010

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check if the filing organization belongs to an affiliated group.
B Check if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated Group Totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......
b	Total lobbying expenditures to influence a legislative body (direct lobbying) .......
c	Total lobbying expenditures (add lines 1a and 1b) ...................
d	Other exempt purpose expenditures ........................
e	Total exempt purpose expenditures (add lines 1c and 1d) ...............
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ......................................	Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2007	(b) 2008	(c) 2009	(d) 2010	(e) Total

2a	Lobbying non-taxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots non-taxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2010

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

(a)

Yes

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? .........................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....

Media advertisements? ....................................

Mailings to members, legislators, or the public? .........................

Publications, or published or broadcast statements? .......................

Grants to other organizations for lobbying purposes? .......................

Direct contact with legislators, their staffs, government officials, or a legislative body? ........

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......

Other activities? If "Yes," describe in Part IV ..........................

Yes

9,712

Total. lines 1c through 1i ...................................

9,712

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 .................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ................

Did the organization agree to carryover lobbying and political expenditures from the prior year? ..........

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) if BOTH Part III-A, lines 1 and 2 are answered “No” OR if Part III-A, line 3 is answered “Yes”.

Dues, assessments and similar amounts from members .....................

Section 162(e) non-deductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).

Current year .........................................

Carryover from last year ....................................

Total ...........................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................

Taxable amount of lobbying and political expenditures (see instructions) ..............

Part IV

Supplemental Information

Complete this part to provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; and Part ll-B, line 1i.
Also, complete this part for any additional information.

Identifier	Return Reference	Explanation
PART II-B, LINE 1 (I), OTHER LOBBYING ACTIVITIES:	SCHEDULE C	THE ORGANIZATION PAYS DUES TO THE NEW HAMPSHIRE HOSPITAL ASSOCIATION AND THE AMERICAN HOSPITAL ASSOCIATION, A PORTION OF WHICH ARE ATTRIBUTABLE TO LOBBYING ACTIVITIES.

Schedule C (Form 990 or 990EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11, or 12.
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

Alice Peck Day Memorial Hospital

Employer identification number

02-0222791

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .......
2	Aggregate contributions to (during year) ...
3	Aggregate grants from (during year) ...
4	Aggregate value at end of year .......

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds may be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit. ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or pleasure) Preservation of an historically importantly land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a–2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements .......................	2a
b	Total acreage restricted by conservation easements ..................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 8/17/06 ........	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the taxable year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting and enforcing conservation easements during the year SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section
170(h)(4)(B)(i) and 170(h)(4)(B)(ii)? ....................................

Yes No

In Part XIV, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.

If the organization elected, as permitted under SFAS 116, not to report in its revenue statement and balance sheet works of
art, historical treasures, or other similar assets held for public exhibition, education or research in furtherance of public service,
provide, in Part XIV, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116, to report in its revenue statement and balance sheet works of art,
historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service,
provide the following amounts relating to these items:

(i)

Revenues included in Form 990, Part VIII, line 1 ........................ SchDMd Bullet

(ii)

Assets included in Form 990, Part X .............................. SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 relating to these items:

Revenues included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990

Cat. No. 52283D

Schedule D (Form 990) 2010

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s accession and other records, check any of the following that are a significant use of its collection
items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIV.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No

If "Yes," explain the arrangement in Part XIV and complete the following table:


c	Beginning balance .................................	1c
d	Additions during the year ..............................	1d
e	Distributions during the year .............................	1e
f	Ending balance ...................................	1f

Did the organization include an amount on Form 990, Part X, line 21? .....................

Yes No

If “Yes,” explain the arrangement in Part XIV.

Part V

Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.

		(a)Current Year	(b)Prior Year	(c)Two Years Back
1a	Beginning of year balance ....	28,065	26,827	26,456
b	Contributions ........
c	Investment earnings or losses ...	-2,225	1,238	371
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........
f	Administrative expenses ....
g	End of year balance ......	25,840	28,065	26,827

Provide the estimated percentage of the year end balance held as:

Board designated or quasi-endowment: SchDMd Bullet

Permanent endowment: SchDMd Bullet

100.000 %

Term endowment: SchDMd Bullet

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations ........................

3a(i)

(ii) related organizations ........................

3a(ii)

If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIV the intended uses of the organization's endowment funds.

Part VI

InvestmentsLand, Buildings, and Equipment. See Form 990, Part X, line 10.

Description of investment		(a) Cost or other basis (investment)	(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	0	927,577		927,577
b	Buildings ................	0	13,343,955	7,387,375	5,956,580
c	Leasehold improvements ............	0	191,748	175,823	15,925
d	Equipment ................	0	17,219,287	13,740,896	3,478,391
e	Other .................	0	2,806,409	809,489	1,996,920
Total. Add lines 1a-1e. (Column (d) should equal Form 990, Part X, column (B), line 10(c).)........					12,375,393

Schedule D (Form 990) 2010

Page 3

Part VII

InvestmentsOther Securities. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)		(b)Book value	(c) Method of valuation: Cost or end-of-year market value
(1)Financial derivatives
(2)Closely-held equity interests
Other








Total. (Column (b) should equal Form 990, Part X, col.(B) line 12.)

Part VIII

InvestmentsProgram Related. See Form 990, Part X, line 13.

(a) Description of investment type		(b) Book value	(c) Method of valuation: Cost or end-of-year market value









Total. (Column (b) should equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. See Form 990, Part X, line 15.

(a) Description				(b) Book value
(1) DUE FROM AFFILIATES				2,348,299








Total. (Column (b) should equal Form 990, Part X, col.(B) line 15.)...........				2,348,299

Part X

Other Liabilities. See Form 990, Part X, line 25.

1.(a) Description of Liability		(b) Amount
Federal Income Taxes		0
DEFERRED ANNUITY		61,218
ESTIMATED 3RD PARTY SETTLEMENTS		328,319
INTEREST RATE SWAP		216,489






Total. (Column (b) should equal Form 990, Part X, col.(B) line 25.)		606,026
2. Fin 48 (ASC 740) Footnote. In Part XIV, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC740).

Schedule D (Form 990) 2010

Page 4

Part XI Reconciliation of Change in Net Assets from Form 990 to Financial Statements
1	Total revenue (Form 990, Part VIII, column (A), line 12) ....................	1	50,831,941
2	Total expenses (Form 990, Part IX, column (A), line 25) .....................	2	49,318,628
3	Excess or (deficit) for the year. Subtract line 2 from line 1 .............	3	1,513,313
4	Net unrealized gains (losses) on investments ..........................	4	-234,459
5	Donated services and use of facilities .............................	5
6	Investment expenses ...................................	6
7	Prior period adjustments ..................................	7
8	Other (Describe in Part XIV) .................................	8	-370,212
9	Total adjustments (net). Add lines 4 - 8 .............................	9	-604,671
10	Excess or (deficit) for the year per financial statements. Combine lines 3 and 9 .........	10	908,642

Part XII Reconciliation of Revenue per Audited Financial Statements With Revenue per Return
1	Total revenue, gains, and other support per audited financial statements .......			1	50,598,246
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIV): ............	2d	13,662
e	Add lines 2a through 2d .....................			2e	13,662
3	Subtract line 2e from line 1.....................			3	50,584,584
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a
b	Other (Describe in Part XIV): ...........	4b	247,357
c	Add lines 4a and 4b.......................			4c	247,357
5	Total Revenue. Add lines 3 and 4c. (This should equal Form 990, Part I, line 12.) ......			5	50,831,941

Part XIII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return
1	Total expenses and losses per audited financial statements .............			1	49,332,290
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities ..........	2a
b	Prior year adjustments ..............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIV): ............	2d	13,662
e	Add lines 2a through 2d......................			2e	13,662
3	Subtract line 2e from line 1.....................			3	49,318,628
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a
b	Other (Describe in Part XIV): ............	4b
c	Add lines 4a and 4b.......................			4c
5	Total expenses. Add lines 3 and 4c. (This should equal Form 990, Part I, line 18.) ......			5	49,318,628

Part XIV

Supplemental Information

Complete this part to provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X; Part XI, line 8; Part XII, lines 2d and 4b; and Part XIII, lines 2d and 4b. Also complete this part to provide any additional information.

Identifier	Return Reference	Explanation
FORM 990, SCHEDULE D, PART X:		THE SYSTEM CONSISTS OF NOT-FOR-PROFIT CORPORATIONS AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE, ALL OF WHICH ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE SYSTEM ADOPTED FASB INTERPRETATION NO. 48 (FIN 48), ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES - AN INTERPRETATION OF FASB STATEMENT NO. 109, EFFECTIVE OCTOBER 1, 2007. THE SYSTEM HAS EVALUATED ITS TAX POSITIONS TAKEN IN ACCORDANCE WITH FIN 48 AND HAS DETERMINED THAT THERE IS NO IMPACT ON THE SYSTEM'S CURRENT TAX-EXEMPT STATUS, OR FINANCIAL POSITION OR RESULTS OF OPERATIONS FOR THE YEARS ENDED SEPTEMBER 30, 2011 AND 2010. WITH FEW EXCEPTIONS, THE SYSTEM IS NO LONGER SUBJECT TO INCOME TAX EXAMINATION BY THE U.S. FEDERAL OR STATE TAX AUTHORITIES FOR YEARS PRIOR TO 2008.
FORM 990, SCHEDULE D, PART XI, LINE 8:		CHANGE IN INTEREST RATE SWAP: $216,489 LOSS ON EXTINGUISHMENT OF DEBT: $148,273 CHANGE IN ANNUITY LIABILITY: $ 5,450
FORM 990, SCHEDULE D, PART XII, LINE 2D:		RENTAL EXPENSES: $13,662
FORM 990, SCHEDULE D, PART XII, LINE 4B:		TEMPORARILY RESTRICTED CONTRIBUTIONS: $241,908 CHANGE IN ANNUITY LIABILITY: $ 5,449
FORM 990, SCHEDULE D, PART XIII, LINE 2D:		RENTAL EXPENSES: $13,662

Schedule D (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE G
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information Regarding
Fundraising or Gaming Activities

Complete if the organization answered "Yes" to Form 990, Part IV, lines 17, 18, or 19,
or if the organization entered more than $15,000 on Form 990-EZ, line 6a.
right arrow

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization
Alice Peck Day Memorial Hospital

Employer identification number

02-0222791

Part I

Fundraising Activities. Complete if the organization answered "Yes" to Form 990, Part IV, line 17.

Indicate whether the organization raised funds through any of the following activities. Check all that apply.

a	Mail solicitations	e	Solicitation of non-government grants
b	Internet and e-mail solicitations	f	Solicitation of government grants
c	Phone solicitations	g	Special fundraising events
d	In-person solicitations

Did the organization have a written or oral agreement with any individual (including officers, directors, trustees

or key employees listed in Form 990, Part VII) or entity in connection with professional fundraising services?

Yes

If “Yes,” list the ten highest paid individuals or entities (fundraisers) pursuant to agreements under which the fundraiser is
to be compensated at least $5,000 by the organization. Form 990-EZ filers are not required to complete this table.

(i) Name and address of individual or entity (fundraiser)	(ii) Activity	(iii) Did fundraiser have custody or control of contributions?		(iv) Gross receipts from activity	(v) Amount paid to (or retained by) fundraiser listed in col. (i)	(vi) Amount paid to (or retained by) organization
	(ii) Activity	Yes	No	(iv) Gross receipts from activity		(vi) Amount paid to (or retained by) organization
GRAHAM-PELTON CONSULTING INC 39 BEECHWOOD RD SUMMIT, NJ07901	CONSULTING		No		44,000
J DONOVAN ASSOCIATES 400 CUMMING CENTER SUITE 333-D BEVERLY, MA01945	CONSULTING		No		42,744
Total .................					86,744

List all states in which the organization is registered or licensed to solicit funds or has been notified it is exempt from registration or licensing.

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50083H

Schedule G (Form 990 or 990-EZ) 2010

Page 2

Part II

Fundraising Events. Complete if the organization answered "Yes" to Form 990, Part IV, line 18, or reported more than $15,000 on Form 990-EZ, line 6a. List events with gross receipts greater than $5,000.

			(a) Event #1 (event type)	(b) Event #2 (event type)	(c) Other Events (total number)	(d) Total Events (Add col. (a) through col. (c))
	1	Gross receipts . . .
	2	Less: Charitable contributions . . .
	3	Gross income (line 1 minus line 2) . . .
	4	Cash prizes . . .
	5	Non-cash prizes . .
	6	Rent/facility costs . .
	7	Food and beverages . .
	8	Entertainment . . .
	9	Other direct expenses .
	10	Direct expense summary. Add lines 4 through 9 in column (d) ...........
	11	Net income summary. Combine lines 3 and 10 in column (d)............

Part III

Gaming. Complete if the organization answered "Yes" to Form 990, Part IV, line 19, or reported more than $15,000 on Form 990-EZ, line 6a.

(a) Bingo

(b) Pull tabs/Instant
bingo/progressive bingo

(c) Other gaming

(d) Total gaming (Add col. (a) through col. (c))

Gross revenue . . . .

Cash prizes . . . .

Non-cash prizes . . .

Rent/facility costs . . .

Other direct expenses . .

Volunteer labor . . .

	Yes
	No

	Yes
	No

	Yes
	No

Direct expense summary. Add lines 2 through 5 in column (d) ........... right arrow

Net gaming income summary. Combine lines 1 and 7 in column (d) .......... right arrow

Enter the state(s) in which the organization operates gaming activities:

Is the organization licensed to operate gaming activities in each of these states? ............

YesNo

If "No," Explain:

10a

Were any of the organization's gaming licenses revoked, suspended or terminated during the tax year? .....

YesNo

If "Yes," Explain:

Does the organization operate gaming activities with nonmembers? .................

YesNo

Is the organization a grantor, beneficiary or trustee of a trust or a member of a partnership or other entity

formed to administer charitable gaming? ...........................

YesNo

Schedule G (Form 990 or 990-EZ) 2010

Page 3

Indicate the percentage of gaming activity operated in:

The organization's facility ......................

13a

An outside facility ........................

13b

Provide the name and address of the person who prepares the organization's gaming/special events books and records:

Name

Address

15a

Does the organization have a contract with a third party from whom the organization receives gaming

revenue? ......................................

YesNo

If "Yes," enter the amount of gaming revenue received by the organization right arrow

$ and the

amount of gaming revenue retained by the third party right arrow

$ .

If "Yes," enter name and address:

Name

Address

Gaming manager information:

Name

Gaming manager compensation right arrow

Description of services provided right arrow

Director/officer Employee Independent contractor

Mandatory distributions:

Is the organization required under state law to make charitable distributions from the gaming proceeds to

retain the state gaming license? ............................

YesNo

Enter the amount of distributions required under state law distributed to other exempt organizations or spent

in the organization's own exempt activities during the tax year right arrow

Part IV

Complete this part to provide additional information for responses to quuestion on Schedule G (see instructions.)

Identifier	ReturnReference	Explanation

Schedule G (Form 990 or 990-EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE H
(Form 990)

Department of the Treasury
Internal Revenue Service

Hospitals

Complete if the organization answered "Yes" to Form 990, Part IV, question 20.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

Alice Peck Day Memorial Hospital

Employer identification number

02-0222791

Part I

Charity Care and Certain Other Community Benefits at Cost

Yes

Does the organization have a charity care policy? If "No," skip to question 6a...........

Yes

If "Yes," is it a written policy? .......................

Yes

If the organization has multiple hospitals, indicate which of the following best describes application of the charity care policy to the various hospitals.

Applied uniformly to all hospitals Applied uniformly to most hospitals Generally tailored to individual hospitals

Answer the following based on the charity care eligibility criteria that applies to the largest number of the organization's patients.

Does the organization use Federal Poverty Guidelines (FPG) to determine eligibility for providing free care to low

income individuals? If "Yes," indicate which of the following is the FPG family income limit for eligibility for free care:

Yes

100% 150% 200% Other

Does the organization use FPG to determine eligibility for providing discounted care to low income individuals? If

"Yes," indicate which of the following is the family income limit for eligibility for discounted care: .....

Yes

200% 250% 300% 350% 400% Other 212 %

If the organization does not use FPG to determine eligibility, describe in Part VI the income based criteria for determining eligibility for free or discounted care. Include in the description whether the organization uses an asset test or other threshold, regardless of income, to determine eligibility for free or discounted care.

Does the organization's policy provide free or discounted care to the "medically indigent"? ......

Yes

Does the organization budget amounts for free or discounted care provided under its charity care policy? ...

Yes

If "Yes," did the organization's charity care expenses exceed the budgeted amount?.........

Yes

If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discounted
care to a patient who was eligibile for free or discounted care?...............

Does the organization prepare an annual community benefit report?.............

Yes

If "Yes," does the organization make it available to the public? ..............

Yes

Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.

Charity Care and Certain Other Community Benefits at Cost

	(c) Total community benefit expense	(d) Direct offsetting revenue	(e) Net community benefit expense	(f) Percent of total expense
a Charity care at cost (from Worksheets 1 and 2) ..	629,484		629,484	1.350 %
b Unreimbursed Medicaid (from Worksheet 3, column a) .	6,028,361	4,034,124	1,994,237	4.270 %
c Unreimbursed costs—other means-tested government programs (from Worksheet 3, column b) ....
dTotal Charity Care and Means-Tested Government Programs .....	6,657,845	4,034,124	2,623,721	5.620 %
Other Benefits e Community health improvement services and community benefit operations (from (Worksheet 4) ....	142,681		142,681	0.310 %
f Health professions education (from Worksheet 5) ..	94,827		94,827	0.200 %
g Subsidized health services (from Worksheet 6) ..	8,973,501	5,676,080	3,297,421	7.060 %
h Research (from Worksheet 7)
i Cash and in-kind contributions to community groups (from Worksheet 8) ..	79,917		79,917	0.170 %
jTotal Other Benefits ...	9,290,926	5,676,080	3,614,846	7.740 %
kTotal. Add lines 7d and 7j. ..	15,948,771	9,710,204	6,238,567	13.360 %

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2010

Schedule H (Form 990) 2010

Page 2

Part II

Community Building Activities Complete this table if the organization conducted any community building activities.

		(c) Total community building expense	(e) Net community building expense	(f) Percent of total expense
1	Physical improvements and housing
2	Economic development	6,778	6,778	0.010 %
3	Community support	8,475	8,475	0.020 %
4	Environmental improvements
5	Leadership development and training for community members
6	Coalition building	1,667	1,667
7	Community health improvement advocacy	13,029	13,029	0.030 %
8	Workforce development
9	Other
10	Total	29,949	29,949	0.060 %

Part III

Bad Debt, Medicare, & Collection Practices

Section A. Bad Debt Expense

Yes

Does the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................

Yes

Enter the amount of the organization's bad debt expense (at cost).....

1,735,949

Enter the estimated amount of the organization's bad debt expense (at cost) attributable to patients eligible under the organization's charity care policy ..

100,000

Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense. In addition, describe the costing methodology used in determining the amounts reported on lines 2 and 3, and rationale for including a portion of bad debt amounts as community benefit.

Section B. Medicare

Enter total revenue received from Medicare (including DSH and IME).....

14,850,102

Enter Medicare allowable costs of care relating to payments on line 5.....

14,703,883

Subtract line 6 from line 5. This is the surplus or (shortfall)........

146,219

Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.
Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.
Check the box that describes the method used:

Cost accounting system Cost to charge ratio Other

Section C. Collection Practices

Does the organization have a written debt collection policy? ...............

Yes

If "Yes," does the organization's collection policy contain provisions on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance? Describe in Part VI......

Yes

Part IV

Management Companies and Joint Ventures

(a) Name of entity	(b) Description of primary activity of entity	(c) Organization's profit % or stock ownership %	(d) Officers, directors, trustees, or key employees' profit % or stock ownership%	(e) Physicians' profit % or stock ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13

Schedule H (Form 990) 2010

Page 3

Part VFacility Information

Section A. Hospital Facilities (list in order of size, measured by total revenue per facility, from largest to smallest) How many hospital facilities did the organization operate during the tax year?1 Name and address		Other (Describe)
1	ALICE PECK DAY MEMORIAL HOSPITAL 125 MASCOMA ST LEBANON,NH03766	X	X	X	X	PHYSICIAN CLINICS

Schedule H (Form 990) 2010

Page 4

Part VFacility Information (continued)

Section B. Facility Policies and Practices.

(Complete a separate Section B for each of the hospital facilities listed in Part V, Section A)

Name of Hospital Facility:ALICE PECK DAY MEMORIAL HOSPITAL

Line Number of Hospital Facility (from Schedule H, Part V, Section A):1

				Yes	No
Community Health Needs Assessment (Lines 1 through 7 are optional for 2010)
1	During the tax year or any prior tax year, did the hospital facility conduct a community health needs assessment (“Needs Assessment”)? If “No,” skip to question 8. .....................		1
	If “Yes,” indicate what the Needs Assessment describes (check all that apply):
	a	A definition of the community served by the hospital facility
	b	Demographics of the community
	c	Existing health care facilities and resources within the community that are available to respond to the health needs of the community
	d	How data was obtained
	e	The health needs of the community
	f	Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups
	g	The process for identifying and prioritizing community health needs and services to meet those needs
	h	The process for consulting with persons representing the community’s interests
	i	Information gaps that limit the hospital facility’s ability to assess all of the community’s health needs
	j	Other (describe in Part VI)
2	Indicate the tax year the hospital facility last conducted a Needs Assessment: 20
3	In conducting its most recent Needs Assessment, did the hospital facility take into account input from persons who represent the community served by the hospital facility? If “Yes,” describe in Part VI how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted.		3
4	Was the hospital facility’s Needs Assessment conducted with one or more other hospital facilities? If “Yes,” list the other hospital facilities in Part VI............................		4
5	Did the hospital facility make its Needs Assessment widely available to the public? ...........		5
	If “Yes,” indicate how the Needs Assessment was made widely available (check all that apply):
	a	Hospital facility’s website
	b	Available upon request from the hospital facility
	c	Other (describe in Part VI)
6	If the hospital facility addressed needs identified in its most recently conducted Needs Assessment, indicate how (check all that apply):
	a	Adoption of an implementation strategy to address the health needs of the hospital facility’s community
	b	Execution of the implementation strategy
	c	Development of a community benefit plan for the facility
	d	Participation in community-wide community benefit plan
	e	Inclusion of a community benefit section in operational plans
	f	Adoption of a budget for provision of services that address the needs identified in the CHNA
	g	Prioritization of health needs in the community
	h	Prioritization of services that the hospital facility will undertake to meet health needs in its community
	i	Other (describe in Part VI)
7	Did the hospital facility address all of the needs identified in its most recently conducted Needs Assessment? If “No,” explain in Part VI which needs it has not addressed together with the reasons why it has not addressed such needs.		7
Financial Assistance Policy
	Did the hospital facility have in place during the tax year a written financial assistance policy that:
8	Explains eligibility criteria for financial assistance, and whether such assistance includes free or discounted care?		8	Yes
9	Used federal poverty guidelines (FPG) to determine eligibility for providing free care to low incomeindividuals?..		9	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for free care: 200.%

Schedule H (Form 990) 2010

Page 5

Part VFacility Information (continued)

				Yes	No
10	Used FPG to determine eligibility for providing discounted care to low income individuals?.........		10	Yes
	If “Yes,” indicate the FPG family income limit for eligibility for discounted care: 212.%
11	Explained the basis for calculating amounts charged to patients?.................		11	Yes
	If “Yes,” indicate the factors used in determining such amounts (check all that apply):
	a	Income level
	b	Asset level
	c	Medical indigency
	d	Insurance status
	e	Uninsured discount
	f	Medicaid/Medicare
	g	State regulation
	h	Other (describe in Part VI)
12	Explained the method for applying for financial assistance?...................		12	Yes
13	Included measures to publicize the policy within the community served by the hospital facility?.......		13	Yes
	If “Yes,” indicate how the hospital facility publicized the policy (check all that apply):
	a	The policy was posted at all times on the hospital facility’s web site
	b	The policy was attached to all billing invoices
	c	The policy was posted in the hospital facility’s emergency rooms or waiting rooms
	d	The policy was posted in the hospital facility’s admissions offices
	e	The policy was provided, in writing, to patients upon admission to the hospital facility
	f	The policy was available upon request
	g	Other (describe in Part VI)
Billing and Collections
14	Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy that explained actions the hospital facility may take upon non-payment?........		14	Yes
15	Check all of the following collection actions against a patient that were permitted under the hospital facility's policies at any time during the tax year:
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments or arrests
	e	Other (describe in Part VI)
16	Did the hospital facility engage in or authorize a third party to engage in any of the following collection actions during the tax year?...................................		16	Yes
	If “Yes,” check all collection actions in which the hospital facility or a third party engaged (check all that apply):
	a	Reporting to credit agency
	b	Lawsuits
	c	Liens on residences
	d	Body attachments
	e	Other (describe in Part VI)
17	Indicate which actions the hospital facility took before initiating any of the collection actions checked in question 16 (check all that apply):
	a	Notified patients of the financial assistance policy upon admission
	b	Notified patients of the financial assistance policy prior to discharge
	c	Notified patients of the financial assistance policy in communications with the patients regarding the patients’ bills
	d	Documented its determination of whether a patient who applied for financial assistance under the financial assistance policy qualified for financial assistance
	e	Other (describe in Part VI)

Schedule H (Form 990) 2010

Page 6

Part VFacility Information (continued)

Policy Relating to Emergency Medical Care
				Yes	No
18	Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that requires the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?..........		18	Yes
	If “No,” indicate the reasons why (check all that apply):
	a	The hospital facility did not provide care for any emergency medical conditions
	b	The hospital facility did not have a policy relating to emergency medical care
	c	The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Part VI)
	d	Other (describe in Part VI)
Charges for Medical Care
19	Indicate how the hospital facility determined the amounts generally billed to individuals who had insurance covering emergency or other medically necessary care (check all that apply):
	a	The hospital facility used the lowest negotiated commercial insurance rate for those services at the hospital facility
	b	The hospital facility used the average of the three lowest negotiated commercial insurance rates for those services at the hospital facility
	c	The hospital facility used the Medicare rate for those services
	d	Other (describe in Part VI)
20	Did the hospital facility charge any of its patients who were eligible for assistance under the hospital facility’s financial assistance policy, and to whom the hospital facility provided emergency or other medically necessary services, more than the amounts generally billed to individuals who had insurance covering such care?.........		20		No
	If “Yes,” explain in Part VI.
21	Did the hospital facility charge any of its patients an amount equal to the gross charge for services provided to that patient?...................................		21		No
	If “Yes,” explain in Part VI.

Schedule H (Form 990) 2010

Page 7

Part VFacility Information (continued)

Section C. Other Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility (list in order of size, measured by total revenue per facility, from largest to smallest) How many non-hospital facilities did the organization operate during the tax year?9
Name and address		Type of Facility (Describe)
1	RAM CENTER FOR COMMUNITY CARE 125 MASCOMA ST 5 LEBANON,NH03766	PRIMARY CARE PHYSICIAN CLINIC
2	RAM CENTER FOR COMMUNITY CARE 125 MASCOMA ST 5 LEBANON,NH03766	PRIMARY CARE PHYSICIAN CLINIC
3	RAM CENTER FOR COMMUNITY CARE 125 MASCOMA ST 5 LEBANON,NH03766	PRIMARY CARE PHYSICIAN CLINIC
4	RAM CENTER FOR COMMUNITY CARE 125 MASCOMA ST 5 LEBANON,NH03766	PRIMARY CARE PHYSICIAN CLINIC
5	RAM CENTER FOR COMMUNITY CARE 125 MASCOMA ST 5 LEBANON,NH03766	PRIMARY CARE PHYSICIAN CLINIC
6	RAM CENTER FOR COMMUNITY CARE 125 MASCOMA ST 5 LEBANON,NH03766	PRIMARY CARE PHYSICIAN CLINIC
7	RAM CENTER FOR COMMUNITY CARE 125 MASCOMA ST 5 LEBANON,NH03766	PRIMARY CARE PHYSICIAN CLINIC
8	RAM CENTER FOR COMMUNITY CARE 125 MASCOMA ST 5 LEBANON,NH03766	PRIMARY CARE PHYSICIAN CLINIC
9	RAM CENTER FOR COMMUNITY CARE 125 MASCOMA ST 5 LEBANON,NH03766	PRIMARY CARE PHYSICIAN CLINIC
10

Schedule H (Form 990) 2010

Page 8

Part VI

Supplemental Information

Complete this part to provide the following information.

1	Required descriptions. Provide the description required for Part I, lines 3c, 6a, and 7; Part II; Part III, lines 4, 8, and 9b; and Part V, Section B, lines 1j, 2, 4c, 6i, 7, 11i, 13i, 17l, 18l, 19e, 21d, 25, and 26.
2	Community health needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any community health needs assessments reported in Part V, Section B.
3	Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4	Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5	Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6	Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7	State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.

Identifier	ReturnReference	Explanation
SCHEDULE H, PART I, LINE 7:		THE COSTS OF CHARITY CARE, MEANS-TESTED PROGRAMS AND SUBSIDIZED HEALTH SERVICES ARE CALCULATED USING THE COST TO CHARGE RATIOS CALCULATED USING A STEP-DOWN COST ALLOCATION METHODOLOGY CONSISTENT WITH MEDICARE COST REPORT METHODOLOGY. THE COST OF FINANCIAL ASSISTANCE AND OTHER COMMUNITY BENEFITS AT COST ARE 13.36% OF TOTAL EXPENDITURES ON FORM 990, PART IX, COLUMN A, LINE 26, EXCLUDING BAD DEBT EXPENSE.
SCHEDULE H, PART I, LINE 7, COLUMN (F):		BAD DEBT EXPENSE REPORTED ON FORM 990 PART IX, LINE 25 WAS EXCLUDED FROM TOTAL EXPENSES FOR THE CALCULATION OF NET COMMUNITY BENEFIT EXPENSES AS A PERCENT OF TOTAL EXPENSE.
SCHEDULE H, PART II		ALICE PECK DAY MEMORIAL HOSPITAL PARTICIPATES IN VARIOUS COMMUNITY BUILDING ACTIVITIES TO PROMOTE AND ADVOCATE FOR THE HEALTH NEEDS OF THE COMMUNITY. SIGNIFICANT ACTIVITIES INCLUDE PARTICIPATION IN THE UPPER VALLEY INTERFAITH PROJECT WHICH PROMOTES ADEQUATE PUBLIC TRANSPORTATION IN THE REGION, INCLUDING AVAILABILITY OF TRANSPORTATION FOR HOSPITAL AND CLINIC VISITS FOR AREA RESIDENTS. APD'S SOCIAL SERVICES DEPARTMENT WORKS WITH PATIENTS WHO SEEK ASSISTANCE WITH LIVING WILLS AND ADVANCE MEDICAL DIRECTIVES. APD PERSONNEL ARE ACTIVELY INVOLVED IN DISASTER AND EMERGENCY PREPAREDNESS PLANNING AND TRAINING ACTIVITIES. THESE ACTIVITIES ARE DESIGNED TO PROMOTE THE HEALTH AND SAFETY OF THE COMMUNITY IN THE EVENT OF WIDESPREAD OR LARGE NATURAL OR OTHER DISASTER, OR IN THE EVENT OF WIDESPREAD VIRAL OUTBREAKS, SUCH AS INFLUENZA. FINALLY, APD PERSONNEL ARE ACTIVE PARTICIPANTS IN THE NEW HAMPSHIRE HOSPITAL ASSOCIATION (NHHA). NHHA ADVOCATES FOR THE CARE AND PROTECTION OF NH HOSPITAL PATIENTS, INCLUDING MAKING QUALITY HEALTH CARE AVAILABLE, AFFORDABLE AND ACCESSIBLE TO ALL REGARDLESS OF ABILITY TO PAY.
SCHEDULE H PART III, LINE 4:		BAD DEBT COST IS CALCULATED USING A COST TO CHARGE RATIO USING A STEP-DOWN COST ALLOCATION METHODOLOGY CONSISTENT WITH MEDICARE COST REPORTING. IN FY 11, ACCOUNTS WRITTEN OFF TO BAD DEBT INCLUDED GROSS CHARGES BEING WRITTEN OFF LESS ANY PAYMENTS RECEIVED AGAINST THOSE CHARGES. ANY CASH COLLECTED ON ACCOUNTS PREVIOUSLY WRITTEN OFF IS INCLUDED AS AN OFFSET TO BAD DEBT EXPENSE AS RECOVERIES OF BAD DEBT. BASED ON LACK OF COMPLETED DOCUMENTATION, WE ESTIMATED THE AMOUNT OF CHARITY CARE IN BAD DEBT EXPENSE BASED ON THE NUMBER OF APPLICATIONS FOR CHARITY CARE. WE BELIEVE THE AMOUNT IS MINIMAL BASED ON OUR EXTENSIVE EFFORTS TO EDUCATE OUR PATIENTS AND STAFF ABOUT OUR VARIOUS PAYMENT PLANS AND CHARITY CARE TO ENSURE THAT PATIENTS WHO QUALIFY FOR ANY OF OUR PROGRAMS UTILIZE THEM. DEPENDING ON THE SPECIFIC CIRCUMSTANCES, A PATIENT MAY BE ELIGIBLE FOR CHARITY CARE, DISCOUNTED CARE, PAYMENT PROGRAMS OR A COMBINATION OF THE ABOVE. DUE TO THESE EFFORTS, WE FEEL THAT AMOUNTS WRITTEN OFF TO BAD DEBT THAT COULD QUALIFY AS CHARITY CARE ARE MINIMAL. FOOTNOTE 1 TO THE AUDITED CONSOLIDATED FINANCIAL STATEMENTS OF ALICE PECK DAY HEALTH SYSTEMS CORP. INCLUDES THE FOLLOWING TO ADDRESS BAD DEBT: ACCOUNTS RECEIVABLE ARE STATED AT THE AMOUNT MANAGEMENT EXPECTS TO COLLECT ON OUTSTANDING BALANCES. MANAGEMENT PROVIDES FOR POSSIBLE UNCOLLECTIBLE AMOUNTS THROUGH A CHARGE TO OPERATIONS AND A CREDIT TO THE VALUATION ALLOWANCE BASED ON ITS ASSESSMENT OF INDIVIDUAL ACCOUNTS AND HISTORICAL ADJUSTMENTS. ACCOUNTS DEEMED UNCOLLECTIBLE ARE WRITTEN OFF THROUGH A CHARGE AGAINST THE ESTABLISHED ALLOWANCE.
SCHEDULE H, PART III, LINE 8:		MEDICARE ALLOWABLE COSTS FOR THE MEDICARE COST REPORT ARE REPORTED IN ACCORDANCE WITH CMS GUIDELINES USING THE COST TO CHARGE RATIO METHODOLOGY.
SCHEDULE H, PART III, LINE 9B:		OUR BAD DEBTS COLLECTION POLICY APPLIES TO ALL PATIENT ACCOUNTS IN A CONSISTENT MANNER. THE POLICY SPECIFICALLY INDICATES THAT, AFTER A SECOND STATEMENT IS SENT WITH NO PAYMENT RECEIVED, A PATIENT ACCOUNTS REPRESENTATIVE WILL CONTACT THE PATIENT BY PHONE TO DETERMINE IF A FINANCIAL ASSISTANCE APPLICATION OR PAYMENT PLAN IS APPROPRIATE. THIS IS COMPLETED TO AVOID FURTHER ESCALATION OF PAST DUE ACCOUNT(S)IF THE PATIENT MAY QUALIFY FOR FULL OR PARTIAL RELIEF UNDER THE CHARITY CARE POLICY. IF THE APPLICATION IS SUCCESSFUL, THEN THE QUALIFYING BALANCE OR BALANCES ARE CLASSIFIED AS CHARITY CARE AND NO LONGER PURSUED FOR COLLECTIONS. ONCE A PATIENT BALANCE IS CLASSIFIED AS CHARITY CARE, IT IS NOT SUBJECT TO COLLECTION ACTIVITIES. ALICE PECK DAY IS COMMITTED TO HELPING OUR PATIENTS ATTAIN QUALITY HEALTHCARE, REGARDLESS OF ABILITY TO PAY. OUR FINANCIAL ASSISTANCE PROGRAMS PROVIDE, ENCOURAGE AND ENABLE OUR PATIENTS TO MAKE HEALTHCARE DECISIONS FREE OF FINANCIAL BARRIERS. WE EDUCATE OUR PATIENTS ABOUT OUR PROGRAMS AND PROVIDE ASSISTANCE PRIOR TO RECEIVING SERVICES, AT REGISTRATION FOR SERVICES AND DURING OUR BILLING PROCESS TO ENSURE THAT ANY AND ALL PATIENTS IN NEED OF ASSISTANCE ARE PROVIDED WITH THE HELP THEY NEED. BROCHURES AND SIGNS ARE PLACED IN HIGH TRAFFIC AREAS SUCH AS THE ER AND REGISTRATION. OUR STAFF IS TRAINED TO IDENTIFY PATIENTS DURING REGISTRATION, PROVIDE INFORMATION AND OFFER HELP IN COMPLETING THE NECESSARY FORMS. DURING OUR BILLING PROCESS, CALLS ARE MADE TO PATIENTS WITH OUTSTANDING BALANCES. OUR STAFF WORKS WITH PATIENTS TO IDENTIFY PROBLEMS THEY ARE FACING IN DEALING WITH OUTSTANDING BALANCES. PATIENTS ARE NOTIFIED AGAIN OF THE MANY TYPES OF FINANCIAL ASSISTANCE AVAILABLE FOR WHICH THEY MAY QUALIFY. PROGRAMS ARE EXPLAINED, AND ASSISTANCE IS OFFERED IF NEEDED, IN COMPLETING THE APPLICATIONS. DUE TO THIS MULTI-LEVEL APPROACH AND STAFF THAT IS TRAINED TO IDENTIFY CLIENTS THAT MAY NEED FINANCIAL ASSISTANCE, VERY FEW QUALIFYING PATIENTS REACH THE POINT OF BAD DEBT. OUR COLLECTION POLICIES AND PROCEDURES IN CONJUCTION WITH OUR SMALL SIZE, ALLOW OUR ORGANIZATION TO PLACE GREAT EMPHASIS ON HELPING ALL PATIENTS WHO MAY BE IN NEED TO APPLY FOR, AND ATTAIN, THE APPROPRIATE LEVEL OF FINANCIAL ASSISTANCE.
SCHEDULE H, PART V, LINE 11:		ALICE PECK DAY MEMORIAL HOSPITAL OFFERS FINANCIAL ASSISTANCE TO PATIENTS DEMONSTRATING NEED. IN MAKING THE NEED DETERMINATION, APD PARTICIPATES WITH AND HONORS THE FOUNDING PRINCIPLES AND GUIDELINES OF THE NEW HAMPSHIRE HEALTH ACCESS NETWORK (NHHAN). ACCORDINGLY, DECISIONS REGARDING THE GRANTING OF FINANCIAL ASSISTANCE WILL BE BASED PRIMARILY ON A PATIENT AND HIS OR HER HOUSEHOLD'S INCOME AND ASSETS. THERE WILL BE MINIMAL CONSIDERATION OF EXPENSES EXCEPT WHEN THEY IDENTIFY AREAS FOR FURTHER INVESTIGATION OR INCOMPLETE OR INACCURATE INFORMATION. THE VALUE OF A PATIENT'S PRINCIPAL RESIDENCE IS NOT CONSIDERED IN QUALIFYING A PATIENT FOR IN-HOUSE ASSISTANCE. APD REQUIRES EXHAUSTION OF OTHER PAYMENT METHODOLOGIES, INCLUDING BUT NOT LIMITED TO: WORKER'S COMPENSATION, VETERANS BENEFITS, MEDICAID, LIABILITY (AUTO ACCIDENTS), VICTIMS OF CRIME AND COBRA. WHEN APPLICABLE, PROOF OF DETERMINATION MAY BE REQUIRED PRIOR TO CONSIDERATION FOR FINANCIAL ASSISTANCE.
SCHEDULE H, PART V, LINE 13:		PLEASE SEE PART V LINE 3 FOR A DESCRIPTION OF THE FINANCIAL ASSISTANCE PROGRAM AND THE EFFORTS MADE TO PUBLICIZE AND PROMOTE THE PROGRAM.
SCHEDULE H, PART V, LINE 19D:		THE HOSPITAL FACILITY PROVIDES UNINSURED PATIENTS WITH A 15% DISCOUNT. AT THE TIME THE DISCOUNT WAS ESTABLISHED THE DISCOUNT APPROXIMATED THE AVERAGE OF THE THREE LOWEST NEGOTIATED COMMERCIAL INSURANCE RATES FOR SERVICES AT THE HOSPITAL FACILTY. THE AVERAGE OF THE THREE LOWEST COMMERICAL INSURANCE RATES WAS APPROXIMATELY 87.5%, THE RATE APPLIED TO UNINSURED PATIENTS WAS LOWER THAN THAT RATE, AT 85%, REPRESENTING A 15% DISCOUNT.
SCHEDULE H, PART VI, LINE 2:		DUE TO OUR RURAL LOCATION AND SIZE, A COLLABORATIVE EFFORT BETWEEN THE UNITED WAY, DARTMOUTH HITCHCOCK MEMORIAL HOSPITAL AND ALICE PECK DAY MEMORIAL HOSPITAL CREATED THE FY 2009 COMMUNITY BENEFITS PLAN. PRIORITY NEEDS AND HEALTH CONCERNS FOR OUR COMMUNITY WERE BASED UPON INFORMATION COLLECTED FROM COMMUNITY NEEDS ASSESSMENTS AND COMMUNITY SURVEYS. IDENTIFIED NEEDS INCLUDED: AVAILABILITY OF ORAL HEALTH, AVAILABILITY OF PRIMARY CARE, PRESCRIPTION ASSISTANCE, TRANSPORTATION, AVAILABILITY OF BEHAVIORAL HEALTH AND ACCESS TO ALCOHOL/DRUG TREATMENT. ALICE PECK DAY USED ITS INFORMATION TO HELP FOCUS ITS COMMUNITY BENEFIT EFFORTS TO MEET THE PRIORITY NEEDS IDENTIFIED IN THE COMMUNITY BENEFIT PLAN. OF SPECIAL NOTE IS THE UPPER VALLEY SMILES PROGRAM THAT HAS SERVED A PRIORITY NEED FOR ORAL HEALTH WITHIN OUR LOCAL COMMUNITY. UPPER VALLEY SMILES HAS TOUCHED THE LIVES OF MANY CHILDREN IN OUR COMMUNITY AND PROVIDED MUCH NEEDED CARE FOR A VERY VULNERABLE POPULATION.
SCHEDULE H, PART VI, LINE 3:		ALICE PECK DAY BELIEVES THAT QUALITY HEALTH CARE SHOULD BE AVAILABLE TO ALL, REGARDLESS OF ABILITY TO PAY. OUR FINANCIAL ASSISTANCE PROGRAMS AND STAFF ARE DEDICATED TO HELPING PEOPLE OBTAIN THE CARE THEY NEED. WE REACH OUT TO OUR PATIENTS IN MANY DIFFERENT WAYS TO ENSURE THAT THEY ARE AWARE THAT HELP IS AVAILABLE AND TO HELP GUIDE THEM THROUGH THE PROCESS. BROCHURES AND SIGNAGE ARE POSTED IN HIGH TRAFFIC AREAS SUCH AS THE EMERGENCY ROOM, REGISTRATION AND THE LOBBY. REGISTRATION STAFF ARE TRAINED TO IDENTIFY PATIENTS WHO MAY BE IN NEED OF FINANCIAL ASSISTANCE. ONCE IDENTIFIED, THE STAFF NOTIFY THE PATIENT THAT APD HAS VARIOUS FORMS OF FINANCIAL ASSISTANCE AND EXPLAIN THAT ASSISTANCE IS AVAILABLE FOR ANYONE WHO MIGHT REQUIRE HELP OR GUIDANCE IN COMPLETING ANY NECESSARY PAPERWORK. IN ADDITION TO THE ABOVE, OUR BILLING STAFF ARE TRAINED TO HELP IDENTIFY AND OFFER ASSISTANCE TO ANY ONE WHO MIGHT REQUIRE FINANCIAL ASSISTANCE. PATIENTS WITH OUTSTANDING CLAIMS ARE CONTACTED BY OUR CREDIT COORDINATOR WHO WORKS WITH THEM TO CLEAR UP BALANCES THROUGH THE VARIETY OF PROGRAMS WE OFFER. ASSISTANCE IS ALSO PROVIDED IN APPLYING FOR FEDERAL/STATE PROGRAMS TO THOSE WHO QUALIFY. SPECIALLY TRAINED STAFF GUIDE APPLICANTS THROUGH THE PROCESS TO ENSURE FORMS ARE FILLED OUT CORRECTLY, ALL REQUIRED DOCUMENTATION IS ATTACHED AND THE APPLICANTS UNDERSTAND WHAT THEY CAN EXPECT TO HAPPEN ALONG THE WAY.
SCHEDULE H, PART VI, LINE 4:		ALICE PECK DAY MEMORIAL HOSPITAL IS PART OF THE LEBANON HEALTH CARE SERVICE AREA. THE LEBANON SERVICE AREA COMPRISES CITIES AND TOWNS IN NEW HAMPSHIRE AND VERMONT. APD'S SERVICE AREA IN NH COMPRISES 15 TOWNS IN ADDITION TO THE CITY OF LEBANON, INCLUDING CANAAN, CORNISH, CROYDON, DORCHESTER, ENFIELD, GRAFTON, GRANTHAM, HANOVER, LYME, NEWPORT, ORANGE, ORFORD, PIERMONT, PLAINFIELD AND WARREN. VERMONT TOWNS INCLUDE EAST THETFORD, FAIRLEE, HARTFORD, HARTLAND, NORTH HARTLAND, NORTH THETFORD, POST MILLS, QUECHEE, SHARON, SOUTH STRAFFORD, STRAFFORD, THETFORD, THETFORD CENTER, VERSHIRE, WEST VERSHIRE, WEST FAIRLEE, WEST HARTFORD, WHITE RIVER JUNCTION AND WOODSTOCK.
SCHEDULE H, PART VI, LINE 5:		ALICE PECK DAY ACTIVELY PROMOTES COMMUNITY-BASED LEADERSHIP DEVELOPMENT. STAFF MEMBERS PARTICIPATE IN TWO LOCAL CHAMBERS OF COMMERCE, LEADERSHIP UPPER VALLEY, FOUNDATION FOR HEALTHY COMMUNITIES, THE RURAL HEALTH COALITION AND THE ADVOCACY TASK FORCE. AS AN ACTIVE MEMBER OF THE COMMUNITY, APD WORKS TO BE PROACTIVE CONCERNING DISASTER READINESS. STAFF HAVE PARTICIPATED IN ONSITE TRAINING FOR DISASTER PREPAREDNESS AS WELL AS OFF-SITE TRAINING WITH OTHER REGIONAL HOSPITALS. COLLABORATIVE EFFORTS INCLUDE ALL HAZARD REGIONAL TRAINING, EMERGENCY RESPONSE TRAINING, AND A REGIONAL MASS CASUALTY RESPONSE PROGRAM TO HELP FACILITATE COOPERATIVE EFFORTS IF SUCH NEEDS ARISE.
SCHEDULE H, PART VI, LINE 6:		ALICE PECK DAY MEMORIAL HOSPITAL IS A CRITICAL ACCESS HOSPITAL LOCATED IN LEBANON NH. THE HOSPITAL IS SERVED BY A BOARD OF TRUSTEES CONSISTING OF LOCAL CITIZENS ACTIVE IN COMMUNITY ACTIVITIES AND ORGANIZATIONS. THE MAJORITY OF BOARD MEMBERS ARE NOT EMPLOYED BY THE HOSPITAL, AND INCLUDE LOCAL GOVERNMENT AND BUSINESS REPRESENTATIVES AS WELL AS PRACTICING INDEPENDENT PHYSICIANS. DESPITE ITS SMALL SIZE, APD IS COMMITTED TO GIVING BACK TO THE COMMUNITY TO THE GREATEST EXTENT POSSIBLE. DURING FY 2011, CASH DONATIONS WERE GIVEN TO MANY PROGRAMS TO HELP THOSE IN NEED. LOCAL FINANCIAL CONTRIBUTIONS HELPED SUPPORT FREE PRIMARY CARE CLINICS FOR THE UNINSURED, PROVIDED TRANSPORTATION FOR THE ELDERLY AND DISABLED TO RECEIVE MEDICAL CARE, AND PROVIDED LOCAL NON PROFIT ORGANIZATIONS WITH MEETING SPACE AND REFRESHMENTS. ALICE PECK DAY SUPPORTED COMMUNITY FLU CLINICS, PROVIDED EMERGENCY PRESCRIPTION DRUG VOUCHERS, SUBSIDIZED SENIOR EXERCISE PROGRAMS, PROVIDED SUPPLIES FOR HURRICANE IRENE RELIEF, AND WORKED TOWARD THE EXPANSION OF LOCAL PUBLIC TRANSPORTATION TO ENSURE ALL THOSE IN NEED OF MEDICAL CARE COULD RECEIVE IT. ONE OF APD'S MOST EXCITING AND CELEBRATED PROGRAMS IS THE UPPER VALLEY SMILES PROGRAM. THIS PROGRAM PROVIDES AN ORAL HEALTH SAFETY NET FOR DISADVANTAGED RESIDENTS WITHIN OUR SERVICE AREA. IN 6 DIFFERENT SCHOOLS OVER 783 STUDENTS RECEIVED ORAL HEALTH EDUCATION. DENTAL SCREENINGS WERE PROVIDED TO 239 OF THOSE CHILDREN, WITH 157 RECEIVING DENTAL SEALANTS AND 126 REFERRED TO DENTISTS FOR RESTORATIVE TREATMENT. NINETEEN CHILDREN REQUIRING URGENT CARE RECEIVED REFERRALS AND HAD THEIR CARE PAID FOR BY APD. ALICE PECK DAY HOSTED TWO FREE ORAL HEALTH CLINICS FOR 18 HOMELESS CHILDREN WHO RECEIVED ORAL HEALTH EDUCATION, A DENTAL CLEANING AND FLUORIDE APPLICATIONS. WITH THE HELP OF TWO GRANTS, APD CONTINUED ITS PILOT WOMEN, INFANTS AND CHILDREN (WIC) ORAL HEALTH INITIATIVE IN LEBANON AND ENFIELD, NH. A TOTAL OF 177 LOW-INCOME CHILDREN AGED 0-10 RECEIVED ORAL HEALTH EDUCATION, A DENTAL SCREENING AND PREVENTATIVE CARE. AS A RESULT OF THIS SUCCESS, AN ADDITIONAL GRANT FROM AN ADDITIONAL FUNDING SOURCE WAS SECURED, ENABLING THE HOSPITAL TO EXPAND ITS WIC ORAL HEALTH PROGRAM INTO THE HARTFORD, VERMONT AREA BEGINNING IN 2012. INDIVIDUALS WERE PROVIDED WITH ASSISTANCE IN APPLYING FOR NH/VT MEDICAID TO ENSURE INCREASED ACCESS TO MEDICAL CARE FOR THIS NEEDY POPULATION. AS A RESULT, A SIGNIFICANT NUMBER OF PEOPLE WERE SUCCESSFULLY ENROLLED AND RECEIVED ONGOING CARE. TO PROMOTE HEALTH PROFESSIONAL EDUCATION, APD PROVIDED CLINICAL UNDERGRADUATE TRAINING TO DARTMOUTH MEDICAL SCHOOL, RIVER VALLEY COMMUNITY COLLEGE, VERMONT TECHNICAL COLLEGE AND LEBANON COLLEGE. APD ANNUALLY SPONSORS DISTRICT-WIDE PROFESSIONAL DEVELOPMENT FOR SCHOOL NURSES IN OUR LOCAL AREA AND FOR OTHERS WITHIN OUR REGION. THESE INITIATIVES AND ONGOING EFFORTS CONTINUE TO ADDRESS SEVERAL OF THE MOST PRESSING COMMUNITY NEEDS AS IDENTIFIED IN OUR COMMUNITY NEEDS ASSESSMENT.
SCHEDULE H, PART VI, LINE 7:		APD FILES A COMMUNITY BENEFIT REPORT IN NEW HAMPSHIRE.

Schedule H (Form 990) 2010

Additional Data

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- TIN:

Schedule I
(Form 990)

Department of the Treasury
Internal Revenue Service

Grants and Other Assistance to Organizations,
Governments and Individuals in the United States

Complete if the organization answered "Yes," to Form 990, Part IV, line 21 or 22.
lBullet

Attach to Form 990

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization
Alice Peck Day Memorial Hospital

Employer identification number
02-0222791

Part I

General Information on Grants and Assistance

Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and
the selection criteria used to award the grants or assistance? ....................................

Yes No

Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States.

Part II

Grants and Other Assistance to Governments and Organizations in the United States. Complete if the organization answered "Yes" to
Form 990, Part IV, line 21 for any recipient that received more than $5,000. Check this box if no one recipient received more than $5,000. Use
Part IV and Schedule I-1 (Form 990) if additional space is needed ......................... lBullet

(a) Name and address of organization or government	(b) EIN	(c) IRC Code section if applicable	(d) Amount of cash grant	(h) Purpose of grant or assistance
(1) GOOD NEIGHBOR HEALTH CLINIC70 N MAIN ST WRJ,VT05001	03-0346949	501(c)3	20,000	OPERATIONAL SUPPORT FOR CLINIC PROVIDING FREE PRIMARY CARE SERVICES TO PATIENTS IN THE UPPER VALLEY ARE OF NH AND WHITE RIVER JUNCTION AREA IN VERMONT. PATIENTS RECEIVING FREE CARE ARE AT OR BELOW 225% OF THE FEDERAL POVERTY LEVEL.
(2) GRAFTON COUNTY SENIOR CITIZENS COUNCILPO BOX 433 LEBANON,NH03766	23-7248316	501(c)3	20,000	Operational support for transportation services for area senior-citizens. The Council provides lift-assisted buses with priority on medical transport for hospital or clinic appointments.

Enter total number of section 501(c)(3) and government organizations ......................... Bullet Image

Enter total number of other organizations ................................ . Bullet Image

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50055P

Schedule I (Form 990) 2010

Page 2

Part III

Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" to Form 990, Part IV, line 22.
Use Schedule I-1 (Form 990) if additional space is needed.

(a)Type of grant or assistance	(b)Number of recipients	(c)Amount of cash grant	(d)Amount of non-cash assistance	(e)Method of valuation (book, FMV, appraisal, other)	(f)Description of non-cash assistance

Part IV

Supplemental Information. Complete this part to provide the information required in Part I, line 2, and any other additional information.

Identifier	Return Reference	Explanation
Schedule I, Part 1, Line 2		As part of APD's Access Improvement Plan developed in 2003, Hospital staff and Board members identified the Grafton County Senior Citizens Council and the Good Neighbor Health Clinic (which also includes the Red Logan Dental Clinic) as essential to providing access to health care in the Upper Valley NH and White River VT areas. Based on the needed services provided, the Board approved on-going monetary support for these organizations. The annual amount to be contributed by APD to these organizations is approved annually through the annual budget process. APD receives and reviews each year the organizations' published annual reports and also maintains informal contacts throughout the year to monitor the organizations' operations and services.

Schedule I (Form 990) 2010

Additional Data

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- TIN:

Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" to Form 990,
Part IV, question 23.
SchJMediumBullet

Attach to Form 990. SchJMediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

Alice Peck Day Memorial Hospital

Employer identification number

02-0222791

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement orprovision of all the expenses described above? If "No," complete Part III to explain....

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
officers, directors, trustees, and the CEO/Executive Director, regarding the items checked in line 1a? ....

Indicate which, if any, of the following the organization uses to establish the compensation of the
organization's CEO/Executive Director. Check all that apply.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? ...............

Participate in, or receive payment from, a supplemental nonqualified retirement plan? ........

Participate in, or receive payment from, an equity-based compensation arrangement? ........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.

For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

For persons listed in form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ...........................

Any related organization? .........................

If "Yes," to line 6a or 6b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Yes

Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regs. section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Privacy Act and Paperwork Reduction Act Notice, see the Intructions for Form 990

Cat. No. 50053T

Schedule J (Form 990) 2010

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use Schedule J-1 if additional space needed.

For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.

Note. The sum of columns (B)(i)-(iii) must equal the applicable column (D) or column (E) amounts on Form 990, Part VII, line 1a.

(A) Name		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
(A) Name		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)
(1) HARRY G DORMAN III	(i) (ii)	263,689		44,962	9,800	18,561	337,012
(2) SUSAN E MOONEY MD	(i) (ii)	224,617		18,126	9,800	25,092	277,635
(3) EVALIE M CROSBY	(i) (ii)	136,678		13,511	4,810	23,160	178,159
(4) DOUGLAS CEDENO MD	(i) (ii)	223,821		27,148	9,800	14,054	274,823
(5) CHRISTOPHER MAZUR MD	(i) (ii)	225,366		15,937	9,100	26,365	276,768
(6) DAVID KRONER MD	(i) (ii)	263,484		21,688	9,800	16,501	311,473
(7) Virginia McDougall MD	(i) (ii)	270,593		2,193		11,094	283,880
(8) Andrew Best MD	(i) (ii)	243,385		552	2,682	7,137	253,756

Schedule J (Form 990) 2010

Page 3

Part III

Supplemental Information

Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 4c, 5a, 5b, 6a, 6b, 7, and 8. Also complete this part for any additional information.

Identifier	Return Reference	Explanation
FORM 990, SCHEDULE J, PART I, LINE 7:		IN FISCAL YEAR 2011, CERTAIN PROVIDERS WERE PAID THROUGH AN RVU (RELATIVE VALUE UNIT) SYSTEM, A PRODUCTIVITY MEASUREMENT SET BY MEDICARE TO ASSIGN VALUE TO SERVICES.
FORM 990, SCHEDULE J, PART II:		SALARY AND BENEFIT EXPENSE FOR THE CEO AND CFO ARE CHARGED TO APD HEALTH SYSTEMS AND THEN ALLOCATED TO ALICE PECK DAY MEMORIAL HOSPITAL AND ALICE PECK DAY LIFECARE INC. BASED ON THE RELATIVE SHARE OF SERVICES PERFORMED FOR THOSE ENTITIES. ON THE AUDITED CONSOLIDATED FINANCIAL STATEMENTS THESE EXPENSES ARE INCLUDED IN SALARIES AND BENEFITS EXPENSE. ON LINE 24(E) OF FORM 990, SCHEDULE IX , THESE EXPENSES ($483,311) HAVE BEEN RECLASSIFIED FROM SALARY AND BENEFIT EXPENSE TO LINE 24(E).

Schedule J (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

Schedule K
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Information on Tax Exempt Bonds

Complete if the organization answered "Yes" to Form 990, Part IV, line 24a. Provide descriptions,
explanations, and any additional information in Schedule O (Form 990).
SchKMediumBullet

Attach to Form 990. SchKMediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization
Alice Peck Day Memorial Hospital

Employer identification number
02-0222791

Part I

Bond Issues

(a) Issuer Name		(b) Issuer EIN	(c) CUSIP #	(d) Date Issued	(e) Issue Price	(f) Description of Purpose	(g) Defeased		(h) On Behalf of Issuer		(i) Pool financing
(a) Issuer Name		(b) Issuer EIN	(c) CUSIP #	(d) Date Issued	(e) Issue Price	(f) Description of Purpose	Yes	No	Yes	No	Yes	No
A	BUSINESS FINANCE AUTHORITY OF THE STATE OF NH	52-1304598		11-30-2010	12,282,000	CURRENT REFUND EXISTING BONDS		X		X		X

Part II

Proceeds

	A		B		C		D
	1 Amount of bonds retired. . . . .
2 Amount of bonds defeased . . . .
3 Total proceeds of issue . . . .	12,282,000
4 Gross proceeds in reserve funds . .
5 Capitalized interest from proceeds.
6 Proceeds in refunding escrow. . . . .	12,237,068
7 Issuance costs from proceeds . . .	44,932
8 Credit enhancement from proceeds.
9 Working capital expenditures from proceeds . .
10 Capital expenditures from proceeds . .
11 Other spent proceeds . .
12 Other unspent proceeds. . .
13 Year of substantial completion . . .	2010
	Yes	No	Yes	No	Yes	No	Yes	No
14 Were the bonds issued as part of a current refunding issue?	X
15 Were the bonds issued as part of an advance refunding issue?		X
16 Has the final allocation of proceeds been made? . .	X
17 Does the organization maintain adequate books and records to support the final allocation of proceeds? .	X

Part III

Private Business Use

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Was the organization a partner in a partnership, or a member of an LLC, which owned property financed by tax-exempt bonds? . . .		X
2 Are there any lease arrangements that may result in private business use of bond-financed property? . . . . .		X

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50193E

Schedule K (Form 990) 2010

Page 2

Part III

Private Business Use (Continued)

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
3a Are there any management or service contracts that may result in private business use?		X
b Are there any research agreements that may result in private business use of bond-financed property? . .		X
c Does the organization routinely engage bond counsel or other outside counsel to review any management or service contracts or research agreements relating to the financed property? .	X
4 Enter the percentage of financed property used in a private business use by entities other than a section 501(c)(3) organization or a state or local government . . . . . . . . . . . . .	0 %
5 Enter the percentage of financed property used in a private business use as a result of unrelated trade or business activity carried on by your organization, another section 501(c)(3) organization, or a state or local government .	0 %
6 Total of lines 4 and 5 . . .. . . . . .	0 %
7 Has the organization adopted management practices and procedures to ensure the post-issuance compliance of its tax-exempt bond liabilities?	X

Part IV

Arbitrage

	A		B		C		D
	Yes	No	Yes	No	Yes	No	Yes	No
1 Has a Form 8038-T, Arbitrage Rebate, Yield Reduction and Penalty in Lieu of Arbitrage Rebate, been filed with respect to the bond issue? . . .		X
2 Is the bond issue a variable rate issue?	X
3a Has the organization or the governmental issuer entered into a hedge with respect to the bond issue?	X
b Name of provider .	TD BANK NA
c Term of hedge . .	5.
d Was the hedge superintegrated? .		X
e Was a hedge terminated? .		X
4a Were gross proceeds invested in a GIC? .		X
b Name of provider .
c Term of GIC . .
d Was the regulatory safe harbor for establishing the fair market value of the GIC satisfied? .
5 Were any gross proceeds invested beyond an available temporary period? .		X
6 Did the bond issue qualify for an exception to rebate? . . .	X

Schedule K (Form 990) 2010

Page 3

Part V

Supplemental Information

Complete this part to provide additional information for responses to questions on Schedule K (see instructions).

Identifier	Return Reference	Explanation

Schedule K (Form 990) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.

OMB No. 1545-0047

2010

Open to Public
Inspection

Name of the organization

Alice Peck Day Memorial Hospital

Employer identification number

02-0222791

Identifier	Return Reference	Explanation
FORM 990, PART I, LINE 5 AND PART V, LINE 2A:		FOR ADMINISTRATIVE PURPOSES, ALICE PECK DAY MEMORIAL HOSPITAL ACTS AS COMMON PAYMASTER FOR BOTH ALICE PECK DAY HEALTH SYSTEMS CORP. AND ALICE PECK DAY LIFECARE CENTER, INC.
FORM 990, PART IV, LINE 34:		INACTIVE ENTITIES THE ORGANIZATION IS RELATED TO ALICE PECK DAY REALTY CORP. (EIN 02-0485369) AND ALICE PECK DAY HEALTH MANAGEMENT CORP.(EIN 02-0485370) THROUGH THE DIRECT CONTROLLING PARENT, ALICE PECK DAY HEALTH SYSTEMS CORP. BOTH ENTITIES ARE INACTIVE AND HOLD NO ASSETS.
FORM 990, PART VI, SECTION A, LINE 6:		ALICE PECK DAY HEALTH SYSTEMS CORP, A CHARITABLE CORPORATION, ACTING BY AND THROUGH ITS BOARD OF TRUSTEES, IS THE SOLE MEMBER OF THE ORGANIZATION.
FORM 990, PART VI, SECTION A, LINE 7A:		ALL TRUSTEES SHALL BE ELECTED BY THE BOARD OF TRUSTEES OF THE MEMBER AT THE ANNUAL MEETING OF THE MEMBER. A NOMINATION SLATE FOR THE TRUSTEES SHALL BE SUBMITTED BY THE GOVERNANCE COMMITTEE OF THE MEMBER. ANY TRUSTEE MAY BE REMOVED AT ANY TIME, WITH OR WITHOUT CAUSE, BY THE MEMBER. VACANCIES ON THE BOARD OF TRUSTEES DUE TO DEATH, RESIGNATION, OR OTHER CAUSE EXCEPT REMOVAL SHALL BE FILLED BY ELECTION BY THE REMAINING MEMBERS OF THE BOARD.VACANCIES CAUSED BY REMOVAL SHALL BE FILLED BY ELECTION BY THE MEMBER. TRUSTEES ELECTED TO FILL VACANCIES SHALL HOLD OFFICE UNTIL THE NEXT ANNUAL MEETING OF THE MEMBER, AT WHICH TIME SUCCESSORS SHALL BE ELECTED IN THE MANNER PROVIDED FOR IN THE CASE OF ORIGINAL ELECTIONS.
FORM 990, PART VI, SECTION A, LINE 7B:		THE ORGANIZATION'S ANNUAL OPERATING BUDGET AND ALL CAPITAL BUDGETS SHALL BE SUBJECT TO APPROVAL BY THE MEMBER. ANY OVERALL STRATEGIC PLAN FOR THE ORGANIZATION, INCLUDING THE DEVELOPMENT OF OFF-SITE FACILITIES, THE ADDITION OF NEW PROGRAMS AND AFFILIATIONS WITH OTHER INSTITUTIONS, SHALL BE CONSISTENT WITH THE STRATEGIC PLAN OF THE MEMBER AS DETERMINED BY THE MEMBER. THE BORROWING OF ANY SUM IN EXCESS OF $50,000 WHICH HAS A STATED TERM OF GREATER THAN ONE YEAR OR WHICH IS SECURED BY A MORTGAGE OF ALL OR ANY PORTION OF THE ORGANIZATION'S REAL PROPERTY OR BY A SECURITY INTEREST IN THE ORGANIZATION'S ASSETS OR REVENUES SHALL BE SUBJECT TO APPROVAL BY THE MEMBER, PROVIDED, HOWEVER, THAT THE APPROVAL BY THE MEMBER SHALL NOT BE NECESSARY FOR ANY BORROWING TO PURCHASE OR LEASE EQUIPMENT OR OTHER PERSONAL PROPERTY SECURED BY A PURCHASE MONEY LIEN OR TITLE RETENTION OR SECURITY AGREEMENT EXCEPT AS INCIDENT TO THE REVIEW OF THE CAPITAL BUDGET. ANY VOLUNTARY DISSOLUTION, MERGER OR CONSOLIDATION OF THE ORGANIZATION OR THE SALE OR TRANSFER OF ALL OR SUBSTANTIALLY ALL OF THE ORGANIZATION'S ASSETS OR THE CREATION OR ACQUISITION OF ANY SUBSIDIARY OR AFFILIATE CORPORATION SHALL BE SUBJECT TO APPROVAL BY THE MEMBER. THE BOARD SHALL SELECT AS CERTIFIED PUBLIC ACCOUNTANTS FOR THE ORGANIZATION THE FIRM WHICH AUDITS THE BOOKS AND RECORDS OF THE MEMBER. THE BOARD SHALL SELECT THE PRESIDENT WHO MUST BE CONFIRMED BY THE MEMBER.
FORM 990, PART VI, SECTION B, LINE 11:		THE COMPLETED FORM 990 IS PROVIDED TO ALL MEMBERS OF THE FINANCE AND GOVERNANCE COMMITTEES OF THE BOARD OF TRUSTEES IN ADVANCE OF THE FILING DEADLINE TO ENABLE A DETAILED AND CONSCIENTIOUS REVIEW BY ALL MEMBERS OF BOTH COMMITTEES. THE COMPLETED FORM 990 IS ALSO DISTRIBUTED TO ALL MEMBERS OF THE FULL BOARD FOR REVIEW NO LATER THAN THE FINAL REGULARLY SCHEDULED BOARD MEETING PRIOR TO THE FILING DEADLINE. ALL QUESTIONS AND CONCERNS ARE ADDRESSED BY THE CHIEF FINANCIAL OFFICER AND INCORPORATED INTO THE FORM 990 AS DEEMED APPROPRIATE. AFTER ALL INPUT FROM THE BOARD, FINANCE, AND GOVERNANCE COMMITTEES HAS BEEN APPROPRIATELY ADDRESSED AND INCORPORATED INTO THE FINAL FORM 990, A VOTE OF ACCEPTANCE OF THE FINAL DOCUMENT IS REQUIRED. THE VOTE IS RECORDED IN THE MINUTES OF THE BOARD OF TRUSTEES PRIOR TO THE FILING OF THE FORM 990. ONCE APPROVED, SENIOR MANAGEMENT FILES THE FINAL FORM 990 WITH THE INTERNAL REVENUE SERVICE AS REQUIRED.
FORM 990, PART VI, SECTION B, LINE 12C:		ALICE PECK DAY HAS A MULTI-FACETED CONFLICT OF INTEREST POLICY. THE BOARD OF TRUSTEES COMPLETES A CONFLICT OF INTEREST QUESTIONNAIRE ON AN ANNUAL BASIS AND ANY NEW MEMBERS COMPLETE THE QUESTIONNAIRE UPON JOINING THE BOARD. AS PART OF OUR ONGOING MONITORING PROCESS, OUR EXECUTIVE ASSISTANT REVIEWS ALL BOARD QUESTIONNAIRES AND DISCLOSURES TO IDENTIFY ANY POTENTIAL CONFLICTS BEFORE THEY ARISE. IN ADDITION, OUR EXECUTIVE ASSISTANT ATTENDS ALL BOARD MEETINGS TO ENSURE THAT IF ANY CONFLICTS ARISE, THEY ARE HANDLED APPROPRIATELY. IF SUCH CONFLICTS ARISE, THE ORGANIZATION COMPLIES WITH THE NEW HAMPSHIRE AND FEDERAL REQUIREMENTS FOR DISCLOSURES OF SUCH EVENTS. THE ORGANIZATION IS COMMITTED TO CONDUCTING ITS BUSINESS IN A MANNER THAT IS BOTH ETHICAL AND LEGAL. AS PART OF THIS COMMITTMENT, A STANDARD OF CONDUCT FORM IS REQUIRED OF ALL EMPLOYEES OF THE ORGANIZATION. THIS IS REVIEWED WITH ALL STAFF UPON HIRE AND ON AN ANNUAL BASIS THEREAFTER. THE STANDARD OF CONDUCT COVERS CONFLICT OF INTEREST AND OTHER VITAL MATTERS TO ENSURE ALL BUSINESS ACTIVITY IS CONDUCTED IN A MANNER THAT IS CONSISTENT WITH THE HIGHEST STANDARDS OF HONESTY, INTEGRITY AND FAIRNESS.
FORM 990, PART VI, SECTION B, LINE 15:		THE COMPENSATION COMMITTEE OF THE ALICE PECK DAY HEALTH SYSTEMS BOARD OF TRUSTESS IS RESPONSIBLE FOR DETERMINING THE COMPENSATION OF THE CHIEF EXECUTIVE OFFICER/PRESIDENT. THE HUMAN RESOURCE DIRECTOR PROVIDES COMPENSATION DATA OF COMPARABLE ORGANIZATIONS WITH APPROXIMATELY THE SAME SIZE STAFF AND SPENDING IN A LOCATION OF SIMILIAR SIZE. THE COMMITTEE DETERMINES THE APPROPRIATE COMPENSATION AND APPROVES THE AMOUNT THAT IS THEN COMMUNICATED TO HUMAN RESOURCES FOR ADJUSTMENT. THE CEO/PRESIDENT IS RESPONSIBLE FOR REVIEWING THE PERFORMANCE OF SENIOR MANAGEMENT STAFF. THE INFORMATION IS BROUGHT TO THE COMPENSATION COMMITTEE OF THE BOARD OF TRUSTEES ALONG WITH A RECOMMENDATION FOR THE SALARY OF EACH INDIVIDUAL. THE COMPENSATION IS DETERMINED THROUGH A VARIETY OF ANALYSIS OF SALARY DATA AND PERFORMANCE. INDIVIDUAL SALARY INCREASES ARE THEN BASED ON OVERALL PERFORMANCE, WITHIN BUDGETED INCREASES FOR THE ORGANIZATION. THE COMPENSATION COMMITEE APPROVES THE BASE COMPENSATION AND SALARY INCREASE AMOUNT.
FORM 990, PART VI, SECTION C, LINE 19:		THE ORGANIZATION MAKES IT GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST.
FORM 990, PART VII, SECTION A, COLUMN E:		DR. SUSAN E. MOONEY IS A PRACTICING PHYSICIAN IN ADDITION TO BEING THE HOSPITAL'S CHIEF MEDICAL OFFICER. SHE WORKED AN AVERAGE OF 60 HOURS PER WEEK, OF WHICH AN AVERAGE OF 40 HOURS PER WEEK WERE SPENT ON EXECUTIVE MATTERS AND 20 IN HER ROLE AS A PHYSICIAN.
FORM 990, PART XI, LINE 2C:		OVERSIGHT OF AUDIT PROCESS THE AUDIT COMMITTEE OVERSEES THE AUDIT PROCESS FOR THE ALICE PECK DAY ENTITIES. THE AUDIT PROCESS FOR THE FINANCIAL STATEMENTS DID NOT CHANGE FROM THE PRIOR YEAR. INDEPENDENT ACCOUNTANTS PERFORMED THE AUDIT FOR THE FISCAL YEARS ENDED 9/30/10 AND 9/30/11.
FORM 990, PART XI, LINE 5:		OTHER CHANGES IN NET ASSETS OR FUND BALANCE: CHANGE IN INTEREST RATE SWAPS: -216,490 LOSS ON EARLY EXTINGUISHMENT OF DEBT: -148,273 UNREALIZED LOSS ON INVESTMENTS: -234,459 CHANGE IN ANNUITY VALUATION: -5,449
HOURS DEVOTED FOR RELATED ORGANIZATION	FORM 990 PART VII	NAME:PAUL R. BOUCHER TITLE:CHAIR- APD LIFECARE HOURS:1

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2010

Additional Data

Software ID:
Software Version:

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" to Form 990, Part IV, line 33, 34, 35, 36, or 37.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.

OMB No. 1545-0047

2010

Open to Public Inspection

Name of the organization

Alice Peck Day Memorial Hospital

Employer identification number

02-0222791

Part I

Identification of Disregarded Entities (Complete if the organization answered "Yes" on Form 990, Part IV, line 33.)

(a) Name, address, and EIN of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

Identification of Related Tax-Exempt Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled organization
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) ALICE PECK DAY HEALTH SYSTEMS CORP 125 MASCOMA ST LEBANON,NH03766 02-0479095	PROMOTE HEALT	NH	501(C)(3)	LINE 11B,II	N/A
(2) ALICE PECK DAY LIFECARE CENTER INC 125 MASCOMA ST LEBANON,NH03766 02-0479094	ASSISTED LIVI	NH	501(C)(3)	LINE 9	APDHS
(3) ALICE PECK DAY REALTY CORP 125 MASCOMA STREET LEBANON,NH037662647 02-0485369	INACTIVE	NH	501(c)(2)		APDHS

For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2010

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust (Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.)

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Type of entity (C corp, S corp, or trust)	(h) Percentage ownership
(1) ALICE PECK DAY HEALTH MANAGEMENT CORP 125 MASCOMA ST LEBANON,NH037662647 02-0485370	INACTIVE	NH	C corp.	100.000 %

Schedule R (Form 990) 2010

Page 3

Part V

Transactions With Related Organizations (Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35, 35A, or 36.)

Note. Complete line 1 if any entity is listed in Parts II, III or IV.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest (ii) annuities (iii) royalties (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .

b Gift, grant, or capital contribution to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c Gift, grant, or capital contribution from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

d Loans or loan guarantees to or for other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

e Loans or loan guarantees by other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

f Sale of assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g Purchase of assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

h Exchange of assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Lease of facilities, equipment, or other assets to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

j Lease of facilities, equipment, or other assets from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .

k Performance of services or membership or fundraising solicitations for other organization(s) . . . . . . . . . . . . . . . . . . . . . .

l Performance of services or membership or fundraising solicitations by other organization(s) . . . . . . . . . . . . . . . . . . . . . .

m Sharing of facilities, equipment, mailing lists, or other assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

n Sharing of paid employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

o Reimbursement paid to other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

p Reimbursement paid by other organization for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

q Other transfer of cash or property to other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

r Other transfer of cash or property from other organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of other organization	(b) Transaction type(a-r)	(c) Amount involved
(1) ALICE PECK DAY HEALTH SYSTEMS CORP	D	1,117,757
(2) ALICE PECK DAY LIFECARE CENTER INC	P	3,648,954
(3) ALICE PECK DAY LIFECARE CENTER INC	D	1,230,536
(4)
(5)
(6)

Schedule R (Form 990) 2010

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership (Complete if the organization answered "Yes" on Form 990, Part IV, line 37.)

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Are all partners section 501(c)(3) organizations?		(e) Share of end-of-year assets	(f) Disproprtionate allocations?		(g) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	(h) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(e) Share of end-of-year assets	Yes	No	(g) Code VUBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2010

Page 5

Part VII

Supplemental Information

Complete this part to provide additional information for responses to questions on Schedule R (see instructions).

Identifier	Return Reference	Explanation

Additional Data

Software ID:
Software Version:

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	1,029,971	462,323
9	Program service revenue (Part VIII, line 2g) .........	42,411,307	50,223,338
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	137,115	106,115
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	48,297	40,165
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	43,626,690	50,831,941
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...		41,450
14	Benefits paid to or for members (Part IX, column (A), line 4) ....		0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	23,580,477	28,733,724
16a	Professional fundraising fees (Part IX, column (A), line 11e)....		86,744
b	Total fundraising expenses (Part IX, column (D), line 25) 370,053
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24f)....	17,285,987	20,456,710
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	40,866,464	49,318,628
19	Revenue less expenses. Subtract line 18 from line 12......	2,760,226	1,513,313
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16)............	28,392,505	33,647,872
21	Total liabilities (Part X, line 26)............	15,278,155	19,624,880
22	Net assets or fund balances. Subtract line 21 from line 20 .....	13,114,350	14,022,992

Sign Here

	Signature of officer	Date

	Type or print name and title.

Paid Preparer's Use Only	Preparer's signature	Date	Check if self- employed	Preparer’s taxpayer identification number (see instructions)
	Firm’s name (or yours if self-employed), address, and ZIP + 4			EIN
				Phone no.


4a	(Code: ) (Expenses $ 45,652,832 including grants of $ 41,450 ) (Revenue $ 50,127,040 )
	ALICE PECK DAY MEMORIAL HOSPITAL IS A COMMUNITY-BASED HOSPITAL OPERATING IN LEBANON NH. THE HOSPITAL BEGAN AS A SMALL COTTAGE HOSPITAL IN 1932. FROM ITS HUMBLE BEGINNINGS, ALICE PECK DAY HAS CONTINUALLY DEMONSTRATED ITS COMMITMENT TO PROVIDE PATIENT-FOCUSED HEALTH CARE SERVICES WHICH IMPROVE THE QUALITY OF LIFE WITHIN ITS COMMUNITY AND PROMOTE WELLNESS FOR ALL. ALICE PECK DAY MEMORIAL HOSPITAL IS A CHARITABLE HEALTH CARE ORGANIZATION WHICH IS DEDICATED TO SERVING ITS COMMUNITY. THIS COMMITMENT INCLUDES GRANTING CREDIT TO PATIENTS, SUBSTANTIALLY ALL OF WHOM ARE LOCAL RESIDENTS. THE HOSPITAL PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS CHARITY CARE POLICY WITHOUT CHARGE OR AT AMOUNTS LESS THAN THE ESTABLISHED RATES. COLLECTIONS ARE NOT PURSUED FOR AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE. THE HOSPITAL MAINTAINS RECORDS TO IDENTIFY AND MONITOR THE LEVEL OF CHARITY CARE IT PROVIDES. THESE RECORDS INCLUDE THE AMOUNT OF CHARGES FOREGONE FOR SERVICES AND SUPPLIES FURNISHED UNDER ITS CHARITY CARE POLICY, THE ESTABLISHED COSTS OF THE SERVICES AND SUPPLIES AND EQUIVALENT SERVICE STATISTICS. FOR THE YEAR ENDED SEPTEMBER 30, 2011: CHARGES FORGONE BASED ON ESTABLISHED RATES WERE $942,000 WITH CHARITY CARE AT COST OF $629,000. ESTIMATED COSTS INCURRED IN EXCESS OF PAYMENT FOR INPATIENT AND OUTPATIENT SERVICES FOR MEDICAID PATIENTS IN THE YEAR ENDED SEPTEMBER 30, 2011 WERE $1,994,000. IN ADDITION TO THE CHARITY CARE SERVICES DESCRIBED ABOVE, THE HOSPITAL PROVIDED A NUMBER OF OTHER SERVICES FOR WHICH LITTLE OR NO PAYMENT WAS RECEIVED. SERVICES INCLUDED COMMUNITY HEALTH SERVICES, HEALTH PROFESSIONAL EDUCATION, COMMUNITY BUILDING ACTIVITIES, AND COMMUNITY BENEFIT PROGRAMS. SERVICES RANGED FROM COMMUNITY FLU CLINICS, UPPER VALLEY SMILES DENTAL PROGRAM, STUDENT AND PROFESSIONAL EDUCATION, EMERGENCY PHARMACY VOUCHERS AND INCLUDED MANY OTHER PROGRAMS WHICH CONTRIBUTED TO AND SUPPORTED OUR COMMUNITY. AS A LOCAL HOSPITAL, ALICE PECK DAY WORKS CLOSELY WITH COMMUNITY ORGANIZATIONS TO ADDRESS COMMUNITY NEEDS. ORGANIZATIONS THAT WERE BENEFICIARIES OF THE HOSPITAL'S STAFF, TIME, AND/OR MATERIALS INCLUDE: ALCOHOLICS ANONYMOUS, AARP, AMERICAN LEGION, AMERICAN RED CROSS, AWAKE SUPPORT GROUP, BONNIE CLAC, BROOKSIDE NURSING HOME, CHILDBIRTH EDUCATION AND POSTPARTUM MASSAGE, COMMUNITY HEALTH DEPARTMENT, DARTMOUTH MEDICAL SCHOOL, ELMIRA COLLEGE, GOOD BEGINNINGS OF SULLIVAN COUNTY, GOOD NEIGHBOR HEALTH CLINIC, GRAFTON COUNTY SENIOR CENTER, GRAFTON COUNTY SENIOR CITIZENS COUNCIL, LEBANON AREA CHAMBER OF COMMERCE, LEBANON COLLEGE, LEBANON HOUSING AUTHORITY, LEBANON SCHOOL BIKE RODEO, LEBANON SCHOOL DISTRICT NATURE PROGRAM, OVER-EATERS ANONYMOUS, RIVER VALLEY COMMUNITY COLLEGE, ROGERS HOUSE, SAVVY SENIORS EXERCISE PROGRAM, STORRS HILL, UNITED VALLEY INTERFAITH PROJECT, UPPER VALLEY SMILES DENTAL PROGRAM, VERMONT INSTITUTE OF NATURAL SCIENCES, AND WEST CENTRAL BEHAVORIAL HEALTH. IN CERTAIN INSTANCES, ASSISTANCE WAS PROVIDED TO THE COMMUNITY FOR WHICH NO VALUE CAN BE PLACED. THIS ASSISTANCE INCLUDED LEADERSHIP IN IDENTIFYING COMMUNITY NEEDS, STAFF COMMITMENT TO VOLUNTEER FOR COMMUNITY ORGANIZATIONS, ADVOCACY AND SUPPORT FOR THE SOCIALY AND PHYSICALY DISADVANTAGED, AND SUPPORT FOR LOCAL PUBLIC SAFETY ORGANIZATIONS. ALICE PECK DAY CONSIDERS CARING FOR OUR COMMUNITY A SPECIAL RESPONSIBILITY THAT WE ARE HONORED TO FULFILL. THROUGH ITS MANY PROGRAMS, DEDICATED STAFF AND UNWAVERING COMMITMENT TO QUALITY CARE, ALICE PECK DAY WORKS TO EXCEED THESE EXPECTATIONS AND MAKE A REAL DIFFERENCE IN OUR COMMUNITY.

4b	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4c	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4d	Other program services. (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses$ 45,652,832

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (check all that apply)		(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(1) MICHAEL R HARRIS CHAIR	1.0	X	X
(2) REV DR GUY JD COLLINS VICE CHAIR	1.0	X	X
(3) JUDSON T PIERSON TREASURER	2.0	X	X
(4) KAREN G KAYEN SECRETARY	1.0	X	X
(5) BARBARA A CALLAHAN CRNA MEDICAL STAFF PRESIDENT	1.0	X	X
(6) MICHAEL J CRYANS TRUSTEE	.5	X
(7) HARRY G DORMAN III PRESIDENT AND CEO	60.0	X	X		308,651	28,361
(8) TERRI C DUDLEY TRUSTEE EMERITUS (NON VOTING)	1.0	X
(9) CLAUDIA C GIBSON AUXILIARY PRESIDENT	.5	X
(10) RICHARD S JENNINGS TRUSTEE	1.0	X
(11) BRUCE N JOHNSTONE TRUSTEE	1.0	X
(12) JENNIFER H JUDKINS TRUSTEE	1.0	X
(13) EDWARD T KERRIGAN TRUSTEE	1.0	X
(14) SARA L KOBYLENSKI TRUSTEE	1.0	X
(15) MIRIAM M MAGUIRE TRUSTEE	.5	X
(16) SUSAN E MOONEY MD VP & MEDICAL DIRECTOR	60.0	X	X	242,743		34,892
(17) MICHAEL PWH PAINE FRCS TRUSTEE	2.0	X

1	Briefly describe the organization’s mission or most significant activities: CRITICAL ACCESS HOSPITAL
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ....	3	21
4	Number of independent voting members of the governing body (Part VI, line 1b) ....	4	18
5	Total number of individuals employed in calendar year 2010 (Part V, line 2a) ...	5	494
6	Total number of volunteers (estimate if necessary) ....	6	106
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ..	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 ..	7b

(A) Name and Title	(B) Average hours per week (describe hours for related organizations in Schedule O)	(C) Position (check all that apply)			(D) Reportable compensation from the organization (W- 2/1099-MISC)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(A) Name and Title
(18) PAUL R BOUCHER CHAIR- APD LIFECARE	1.0	X
(19) MARTY P CANDON TRUSTEE	1.0	X
(20) MARK E MELENDY TRUSTEE	1.0	X
(21) SHELLY L MOSES TRUSTEE	1.0	X
(22) CLOSEY F DICKEY TRUSTEE EMERITUS (NON VOTING)	1.0	X
(23) BEVERLY A RANKIN PART YEAR VP & CNO	60.0	X	X		8,087		2,040
(24) JAMES R CALLAN PART YEAR TRUSTEE	1.0	X
(25) J TODD MILLER COO	60.0		X		133,757		15,540
(26) EVALIE M CROSBY VP FINANCE AND CFO	60.0		X			150,189	27,970
(27) DOUGLAS CEDENO MD PHYSICIAN	40.0			X	250,969		23,854
(28) CHRISTOPHER MAZUR MD PHYSICIAN	40.0			X	241,303		35,465
(29) DAVID KRONER MD PHYSICIAN	40.0			X	285,172		26,301
(30) Virginia McDougall MD Physician	40.0			X	272,786		11,094
(31) Andrew Best MD Physician	40.0			X	243,937		9,819

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	1,678,754	458,840	215,336

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512, 513, or 514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d
e	Government grants (contributions)1e

f	All other contributions, gifts, grants, and similar amounts not included above1f		462,323
g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			462,323
			Business Code
2a	PATIENT SERVICE REVENUE		621,400	49,962,376	49,962,376
b	OTHER OPERATING REVENUE		621,400	164,664	164,664
c	NUTRITIONAL REVENUE		900,099	96,298			96,298
d
e
f	All other program service revenue .
g	Total. Add lines 2a–2f........			50,223,338
3	Investment income (including dividends, interest
	and other similar amounts).....			77,420			77,420
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties............			0
		(i) Real	(ii) Personal
6a	Gross Rents	53,827
b	Less: rental expenses	13,662
c	Rental income or (loss)	40,165
d	Net rental income or (loss).......			40,165
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	1,909,789	17,351
b	Less: cost or other basis and sales expenses	1,775,758	122,687
c	Gain or (loss)	134,031	-105,336
d	Net gain or (loss)..........			28,695
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...			0
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Miscellaneous Revenue			Business Code
11a
b
c
d	All other revenue ....
e	Total. Add lines 11a–11d ......			0
12	Total revenue. See Instructions....			50,831,941	50,127,040		173,718


				(A) Beginning of year		(B) End of year
1	Cashnon-interest-bearing ..........			1,955	1	296,478
2	Savings and temporary cash investments .......			4,464,824	2	6,445,524
3	Pledges and grants receivable, net .........			8,764	3	73,430
4	Accounts receivable, net .........			6,151,124	4	7,551,295
5	Receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of
	Schedule L ..........				5
6	Receivables from other disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B). Complete Part II of
	Schedule L ..........				6
7	Notes and loans receivable, net .............				7
8	Inventories for sale or use ..............			1,158,009	8	1,220,966
9	Prepaid expenses and deferred charges ............			194,503	9	372,898
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	34,488,976
b	Less: accumulated depreciation. .....	10b	22,113,583	11,400,298	10c	12,375,393
11	Investments—publicly traded securities ..........			2,555,238	11	2,827,079
12	Investments—other securities. See Part IV, line 11 ......			8,500	12	8,500
13	Investments—program-related. See Part IV, line 11 ..				13
14	Intangible assets .........			150,291	14	128,010
15	Other assets. See Part IV, line 11 ...........			2,298,999	15	2,348,299
16	Total assets. Add lines 1 through 15 (must equal line 34)...			28,392,505	16	33,647,872
17	Accounts payable and accrued expenses .			6,020,355	17	6,379,747
18	Grants payable ..........				18
19	Deferred revenue ..........				19
20	Tax-exempt bond liabilities ..........			9,021,000	20	12,144,107
21	Escrow or custodial account liability. Complete Part IV of Schedule D..				21
22	Payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........				22
23	Secured mortgages and notes payable to unrelated third parties ..				23
24	Unsecured notes and loans payable to unrelated third parties ....				24	495,000
25	Other liabilities. Complete Part X of Schedule D.....			236,800	25	606,026
26	Total liabilities. Add lines 17 through 25.....			15,278,155	26	19,624,880
	Organizations that follow SFAS 117, check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets .....			11,576,659	27	13,051,788
28	Temporarily restricted net assets .....			1,509,626	28	945,364
29	Permanently restricted net assets .....			28,065	29	25,840
	Organizations that do not follow SFAS 117, check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds .....				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances .....			13,114,350	33	14,022,992
34	Total liabilities and net assets/fund balances .....			28,392,505	34	33,647,872